Hearings to examine medication management in VA healthcare.

1[Senate Hearing 119-246]2[From the U.S. Government Publishing Office]34                                                    S. Hrg. 119-24656                 MEDICATION MANAGEMENT IN VA HEALTHCARE7=======================================================================89                                HEARING1011                               BEFORE THE1213                     COMMITTEE ON VETERANS' AFFAIRS14                          UNITED STATES SENATE1516                    ONE HUNDRED NINETEENTH CONGRESS1718                             FIRST SESSION1920                               __________2122                            DECEMBER 3, 20252324                               __________2526       Printed for the use of the Committee on Veterans' Affairs2728[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]2930        Available via the World Wide Web: http://www.govinfo.gov3132                              __________3334               U.S. GOVERNMENT PUBLISHING OFFICE3562-271 PDF            WASHINGTON : 202636=======================================================================3738                 SENATE COMMITTEE ON VETERANS' AFFAIRS3940                     Jerry Moran, Kansas, Chairman41John Boozman, Arkansas               Richard Blumenthal, Connecticut,42Bill Cassidy, Louisiana                  Ranking Member43Thom Tillis, North Carolina          Patty Murray, Washington44Dan Sullivan, Alaska                 Bernard Sanders, Vermont45Marsha Blackburn, Tennessee          Mazie K. Hirono, Hawaii46Kevin Cramer, North Dakota           Margaret Wood Hassan, New47Tommy Tuberville, Alabama                Hampshire48Jim Banks, Indiana                   Angus S. King, Jr., Maine49Tim Sheehy, Montana                  Tammy Duckworth, Illinois50                                     Ruben Gallego, Arizona51                                     Elissa Slotkin, Michigan5253                     David Shearman, Staff Director54                Tony McClain, Democratic Staff Director5556                            C O N T E N T S5758                              ----------5960                            December 3, 20256162                                SENATORS6364                                                                   Page65Hon. Jerry Moran, Chairman, U.S. Senator from Kansas.............     166Hon. Richard Blumenthal, Ranking Member, U.S. Senator from67  Connecticut....................................................     768Hon. Tommy Tuberville, U.S. Senator from Alabama.................    1169Hon. Mazie K. Hirono, U.S. Senator from Hawaii...................    1270Hon. Tim Sheehy, U.S. Senator from Montana.......................    1471Hon. Angus S. King, Jr., U.S. Senator from Maine.................    1672Hon. Margaret Wood Hassan, U.S. Senator from New Hampshire.......    187374                               WITNESSES75                                Panel I7677Alyssa Hundrup, Director, Health Care, U.S. Government78  Accountability79  Office.........................................................     28081Julie Kroviak, MD, Principal Deputy Assistant Inspector General82  in the role of Acting Assistant Inspector General for83  Healthcare Inspections, Office of Inspector General, U.S.84  Department of Veterans Affairs.................................     48586Erin Fletcher, Psy.D., Warrior Care Network Director, Wounded87  Warrior Project................................................     58889                                Panel II9091Ilse Wiechers, MD, MPP, MHS, Acting Deputy Assistant Under92  Secretary for Health for Patient Care Services, Veterans Health93  Administration, U.S. Department of Veterans Affairs accompanied94  by Thomas Emmendorfer, Pharm.D., Executive Director, Pharmacy95  Benefits Management (PBM) Services.............................    219697                                APPENDIX98                           Opening Statement99100Hon. Richard Blumenthal..........................................    31101102                          Prepared Statements103104Alyssa Hundrup, Director, Health Care, U.S. Government105  Accountability106  Office.........................................................    37107108Julie Kroviak, MD, Principal Deputy Assistant Inspector General109  in the role of Acting Assistant Inspector General for110  Healthcare Inspections, Office of Inspector General, U.S.111  Department of Veterans Affairs.................................    57112113Erin Fletcher, Psy.D., Warrior Care Network Director, Wounded114  Warrior Project................................................    63115116Ilse Wiechers, MD, MPP, MHS, Acting Deputy Assistant Under117  Secretary for Health for Patient Care Services, Veterans Health118  Administration, U.S. Department of Veterans Affairs............    71119120                       Submission for the Record121122Letter dated November 13, 2025 from Ranking Member Richard123  Blumenthal to Secretary Douglas Collins, U.S. Department of124  Veterans Affairs...............................................    87125126                        Questions for the Record127128Department of Veterans Affairs response to questions submitted129  by:130131  Hon. Jerry Moran...............................................    91132  Hon. Richard Blumenthal........................................    95133  Hon. Mazie K. Hirono...........................................    98134  Hon. Jim Banks.................................................   102135136Office of Inspector General, Department of Veterans Affairs137  response to questions submitted by:138139  Hon. Margaret Wood Hassan......................................   105140  Hon. Bill Cassidy..............................................   106141142                       Statements for the Record143144American College of Clinical Pharmacy............................   111145146American Legion, Dr. Marie Black, Health Policy Analyst,147  Veterans' Affairs and Rehabilitation Division..................   115148149American Psychiatric Association.................................   121150151Fleet Reserve Association, Theodosius Lawson, Director,152  Legislative Programs...........................................   124153154Grunt Style Foundation, Derek Blumke, Veteran Impact Fellow......   128155156Honorable David J. Shulkin, MD, Ninth Secretary, U.S. Department157  of Veterans Affairs............................................   140158159Jewish War Veterans of the USA (JWV), Kenneth Greenberg, National160  Executive Director.............................................   143161162Navis Clinical Laboratories, Anthony Hayes, Chief Growth Officer.   146163164Senseye, Inc., David Zakariaie, Chief Executive Officer..........   150165166Veterans of Foreign Wars of the United States (VFW), Meggan167  Coleman, Associate Director....................................   154168169Veterans Strategic Solutions, John Spagnola, President...........   161170171  Attachment: VA's Informed Consent Form for Opioids.............   166172173                         MEDICATION MANAGEMENT174                            IN VA HEALTHCARE175176                              ----------177178                      WEDNESDAY, DECEMBER 3, 2025179180                                       U.S. Senate,181                            Committee on Veterans' Affairs,182                                                    Washington, DC.183    The Committee met, pursuant to notice, at 4 p.m., in Room184SR-418, Russell Senate Office Building, Hon. Jerry Moran,185Chairman of the Committee, presiding.186187    Present: Senators Moran, Tuberville, Sheehy, Blumenthal,188Hirono, Hassan, and King.189190             OPENING STATEMENT OF HON. JERRY MORAN,191               CHAIRMAN, U.S. SENATOR FROM KANSAS192193    Chairman Moran. Good afternoon and welcome. I know that194Senator Blumenthal is running a few minutes late, but on his195way, and I assume that we'll have a number of our colleagues196join us. We have a vote at 4:30, so we'll have to figure out197that circumstance as well.198    I appreciate our witnesses joining us today and for the199important work that you all do to support our veterans and200their families. As we know, our Nation owes veterans the201assurance of receiving safe, high quality, and effective care202through the Department of Veterans Affairs. This includes203making certain that the medications that are being prescribed204are designed to support their recovery from trauma, pain, and205mental health challenges, and are being paired correctly with206the right support system. This responsibility is central to207this Committee's mission, and it is the focus of today's208discussion.209    Recent reporting by The Wall Street Journal has raised210concerns about the use of multiple central nervous system211medications among veterans, often referred to as ``combat212cocktail.'' These stories raise the question of how widespread213these practices are, their origins, how the VA is addressing214this issue, and what VA's oversight and accountability215mechanisms are in these instances. Medication is critical to216the overall care and well-being of many veterans and nothing217from today's hearing should suggest that veterans should218hesitate to seek treatment or that evidence-based medications219are unsafe or unwelcome in any way.220    Over the past decade, the VA has made significant progress221in reducing opioid prescriptions through promoting safer222options, expanding programs that support holistic health, and223implementing new oversight measures to identify high risk224medication combinations. This hearing, however, provides an225opportunity to assess progress, discuss effective strategies,226and identify gaps that still remain. Veterans deserve the trust227in the system, and that's exactly why we're here today.228    This includes understanding how the VA trains clinicians,229monitors prescribing practices, and implements policy to make230certain veterans have access to non-medication options like231therapy, pain management, and community programs, along with232discussing whether private sector models or technologies can233offer insights and ultimately help the VA to better serve234veterans.235    Today we'll hear from VA officials who oversee prescribing236practices and mental health policies across the system. The237goal is simple: simply want to understand the scope of this238issue and determine what steps the VA and Congress can take to239guarantee that veterans receive safe, effective, and240personalized care. The men and women who have served our Nation241deserve nothing less.242    As I indicated, Senator Blumenthal is expected to join us243shortly and we are going to proceed with the first panel.244Testifying on the first panel today, which is on my sheet the245second panel, is Dr. Julie Kroviak, Principal Deputy Assistant246Inspector General for the Healthcare Inspections, U.S.247Department of Veterans Affairs; Alyssa Hundrup, Director,248Health Care at U.S. Government Accountability Office; and Erin249Fletcher, Wounded Warrior Project.250    I appreciate our witnesses willing to testify, and we'll251begin. Ms. Hundrup?252253                            PANEL I254255                              ----------256257   STATEMENT OF ALYSSA HUNDRUP, DIRECTOR, HEALTH CARE, U.S.258                GOVERNMENT ACCOUNTABILITY OFFICE259260    Ms. Hundrup. Chairman Moran, Ranking Member Blumenthal, and261Members of the Committee, thank you for the opportunity to262discuss our work related to medication management at VA.263    My testimony today covers various related GAO report264findings and recommendations. Effective medication management265is essential to ensure veterans receive safe and comprehensive266treatment. This is particularly important for veterans267experiencing mental health conditions, which have been a268persistent and growing issue. Many veterans also live with269chronic pain, often because of injuries from their military270service.271    Veterans may receive medications such as antidepressants or272mood stabilizers, as well as opioids for pain management. Some273veterans have multiple chronic and mental health conditions,274which may necessitate the use of numerous medications,275increasing the risk of polypharmacy. If managed improperly,276polypharmacy can lead to adverse health outcomes or even277overdose or death. As such, it is critical that VA ensure it is278offering effective treatment, including medication as well as279non-pharmacological options such as therapy to reduce the risk280of negative outcomes.281    In 2019, we examined VA providers' treatment plan decisions282for veterans with mental health conditions. We found veterans283received a range of treatments including talk therapy, one or284more psychiatric medications such as anti-anxiety or anti-285depressants, or a combination of the two. At that time, VA did286not have guidance on or monitor providers' documentation of287required treatment options in the plans. So, we made two288recommendations to address these issues.289    Since then, VA agreed with and took action to implement the290recommendations. Specifically, VA providers are now required to291record mental health treatment plans as separate easily292identifiable documents in medical records. The plans are to293clearly show what treatment is being provided, the different294treatments that were considered, and whether any changes may295need to be further considered going forward.296    VA also developed an approach for monitoring the297consideration of different evidence-based treatments, including298both the prescribing of medications and therapy options. With299this approach, VA is in a better position to ensure providers300are considering all available options and providing the most301appropriate treatment to each veteran. Importantly, with this302information, VA is also in a position to evaluate the303prevalence and appropriateness of polypharmacy and minimize the304risks that it can bring including overdose or death.305    Additionally, we've examined issues related to VA's306implementation of its Opioid Safety Initiative. At the time of307our report, VA had reduced opioid prescribing rates, but we308found VA did not consistently follow some risk mitigation309strategies, such as conducting annual urine drug screening or310requiring informed consent for long-term prescribing. We made311recommendations to address these issues and VA has implemented312them.313    For example, VA created a planning tool for primary care314providers related to reviewing and documenting each of the risk315mitigation strategies in veterans' medical records. With this316tool, VA can better ensure providers are following the317strategies. In light of the very serious risks that opioids318pose, including addiction and overdose, it is critical that VA319ensure it is maintaining careful oversight of prescribing so320that it is done in a safe and effective manner.321    Lastly, the availability of mental health services is322especially important for service members transitioning out of323the military as this is a particularly vulnerable time. The324transition period can bring stressors related to housing,325employment, and family reintegration, and these veterans are326susceptible to mental health conditions. In our 2024 report,327examining mental health services for transitioning service328members, we found VA and DoD identified a number of helpful329touch points such as pre-separation counseling, but the two330departments have not assessed the effectiveness of their331collective efforts, and we recommended they do so.332    VA has also agreed with this recommendation and stated that333it will coordinate with DoD to establish a plan of action to334implement it, including identifying any gaps in services or335duplicative efforts. It's important for VA to take action to336address our recommendation, and we will carefully monitor the337steps that VA takes going forward.338    Addressing our recommendation will help to ensure that339departments the are most effectively offering mental health340services to service members and veterans as they readjust to341civilian life. This concludes my prepared statement. I'd be342happy to answer any questions that you may have. Thank you.343344    [The prepared statement of Ms. Hundrup appears on pages 37-34556 of the Appendix.]346347    Chairman Moran. Dr. Kroviak, welcome, and thank you for348your testimony.349350  STATEMENT OF JULIE KROVIAK, MD, PRINCIPAL DEPUTY ASSISTANT351  INSPECTOR GENERAL IN THE ROLE OF ACTING ASSISTANT INSPECTOR352    GENERAL FOR HEALTHCARE INSPECTIONS, OFFICE OF INSPECTOR353          GENERAL, U.S. DEPARTMENT OF VETERANS AFFAIRS354355    Dr. Kroviak. Chairman Moran, Members of the Committee, I am356pleased to testify about the oversight conducted by the Office357of Inspector General regarding VA's medication management358practices.359    A fundamental healthcare activity is a medication360reconciliation process involving providers, patients, and their361caregivers, that ensures they are aware of all medications that362patient is prescribed and taking, including over the counter363and supplements.364    Medication reconciliation required by VA can be time and365labor intensive, but it helps verify that patients are taking366their medications as prescribed, and that each medication's367risk and potential side effects are understood. It can also368reveal or prevent duplicative treatments, contraindications due369to allergies, and potentially dangerous drug interactions.370    Medication reconciliation is most critical during care371transitions, such as when a patient is discharged from a372hospital, moves between different levels of care, or receives373VA and community care. For those patients with chronic or374difficult to treat conditions including mental health375conditions, the risk of polypharmacy, being prescribed multiple376medications, is real, but it does not always mean a patient is377receiving poor care.378    Veterans are at higher risk for psychotropic polypharmacy,379that is, being prescribed more than two medications that affect380mind, mood, and behavior. This can occur because of their381distinct military experiences that lead to complex and382treatment-resistant mental health diagnoses.383    The OIG has noted deficiencies in medication management in384several of our reports on VA healthcare. We uncovered non-385compliance with required processes for patients being386discharged from acute mental health care settings. For example,387only 37 percent of electronic health records at the388Philadelphia VA included clear discharge medication389instructions, which are essential to prevent medication errors390post-hospitalization, and ensuring continued recovery.391    Patients must also be educated on potential risks392associated with their prescriptions. Many anti-depressants, for393instance, carry ``black box'' warnings due to their increased394risk of suicidal thoughts, particularly in young adults. One395tragic case reviewed by the OIG revealed serious deficiencies396when a young veteran who ultimately died by suicide was397prescribed an anti-depressant without being educated on the398risks, and was not provided timely follow-up care to evaluate399responses to this new medication. This case highlights the400critical value of patient education and timely follow-up care.401    In addition to challenges with safe prescribing within VA,402the OIG is concerned with safe prescribing for veterans403receiving community care. A significant, troubling area remains404the oversight of opioid prescriptions written by community care405providers. VA is required to ensure community providers review406and acknowledge VA's Opioid Safety Initiative (OSI) guidelines.407However, we found inadequate oversight of VA's third-party408administrators' certification that community providers reviewed409these guidelines. When community providers are not even aware410of VA's expectations for safe opioid prescribing, VA cannot411guarantee the safety of those veterans referred to the412community for chronic and acute pain management.413    Our review of the VA Eastern Kansas Health Care System414highlighted further inadequacies in coordination and oversight415of medication management involving community providers. Among416other issues related to patient safety for veterans referred to417the community, we found incomplete documentation verifying safe418opioid prescribing practices and a lack of documented419medication reconciliation by community providers.420    In conclusion, VA's dedicated clinical staff work421tirelessly to provide high quality care tailored to each422veteran's needs. Such care can involve multiple treatment423modalities and medications. Patients and caregivers must be424empowered to manage their care with accurate medication425instructions and understanding of treatment expectations and426knowledge of potential side effects for each medication.427    The OIG is committed to independent oversight. Our teams of428dedicated medical professionals are uniquely positioned to429assess and drive meaningful improvements in the quality of care430delivered by both VA and community providers. Chairman Moran,431Ranking Member Blumenthal, and Committee members, I am happy to432take any questions you may have.433434    [The prepared statement of Dr. Kroviak appears on pages 57-43562 of the Appendix.]436437    Chairman Moran. Thank you, Doctor. Erin Fletcher, welcome438again. Your testimony will be received.439440   STATEMENT OF ERIN FLETCHER, PSY.D., WARRIOR CARE NETWORK441               DIRECTOR, WOUNDED WARRIOR PROJECT442443    Dr. Fletcher. Thank you. Chairman Moran, Ranking Member444Blumenthal, and distinguished Committee members, thank you for445today's hearing and for the honor to join you on behalf of446Wounded Warrior Project and the warriors and families we serve.447    Our vision to foster the most successful, well-adjusted448generation of wounded service members in our Nation's history,449brings with it the responsibility to identify, address, and450serve the mental health needs of veterans who reach out for451help. In our most recent Warrior Survey, 77 percent of warriors452reported PTSD and more than half presented with moderate to453severe PTSD symptoms at the time of the survey. Nearly two in454three reported one or more mental health conditions, and for455many of the warriors we support, mental health challenges can456be worsened further by poor sleep, chronic pain, and feelings457of isolation.458    Recent reporting about polypharmacy has highlighted how459overmedication can be one of the many challenges veterans face460on their road to recovery. Poor access to therapy, canceled461appointments, and stigma can also frustrate even those who are462most motivated to find care. But there is reason for hope and463we can frame strategies for improvement around stopping464overmedication, increasing access to care, and embracing465innovation. Regarding overmedication, recent research has shown466that 28 percent of post-9/11 veterans receiving VA mental467health care, met criteria for central nervous system468polypharmacy.469    One way to help reverse these trends will be for Congress470and VA to continue their investment in precision medicine. By471moving beyond one-size-fits-all care, precision medicine472enables more accurate decisions that improve outcomes and473reduce unnecessary or ineffective treatments. Congress helped474launch VA's initiative for precision mental health to identify475and validate brain and mental health biomarkers, and translate476those findings into improved clinical care for veterans. With477consistent support and funding, as well as expansion to478consider low level blast injuries, this initiative can479transform the way medication can supplement evidence-based480therapy.481    Increasing access to care will help move away from what482some veterans observe to be a medication first approach at VA,483in which prescriptions are offered before therapy or without484consistent access to evidence-based treatments. But as our485country is struggling with training enough providers to meet486increasing demand for mental healthcare, we can broaden our487perspective on access. Veterans increasingly express interest488in non-pharmacological and complementary therapies to489supplement their clinical treatment. Mindfulness, yoga,490acupuncture, Tai Chi, and other integrative approaches provide491coping skills, stress reduction, and support between therapy492sessions.493    Congress and VA can help extend more access to approaches494like these by renewing commitment to VA's whole health program.495Even with over 100 whole health locations, availability still496widely varies across VA facilities. Without a consistent497centralized implementation model, many veterans remain unaware498of available resources or encounter barriers in accessing them.499Moreover, capacity constraints and frontline clinical treatment500make access to these services even harder to obtain. These501barriers can lead veterans relying solely on pharmacological502interventions.503    Last, innovation can help set new strategies to ensure504veterans have access to evidence-based treatment. Forward505thinking approaches to case management are one area where we506can drive change. We found success with offering veterans507regular touch points to reduce frustration, ease confusion, and508help them stay engaged while they navigate the clinical system.509In a VA context, one example that we have found extremely510effective is the post-9/11 Military2VA (M2VA) Case Management511Program.512    This Public-Private Partnership (P3) model allows VAs to513place liaisons at certain partnership sites as veterans514complete specialized treatment within the community. For515example, VA liaisons are onsite at our Warrior Care Network516academic medical centers where veterans receive intensive517outpatient care. The VA liaisons help veterans obtain VA518medical records, schedule follow-up appointments at VA after519discharge, and serve as a direct point of contact should the520veteran have questions about their VA care in the future.521    At these sites, 90 percent of participating veterans return522to VA for ongoing care, which is evidence that structured,523proactive, and collaborative transition support helps prevent524veterans from falling through the cracks and help maintain525gains achieved in treatment.526    In conclusion, I'd like to recognize that VA is our biggest527and most important partner in helping veterans access the care528and support they need. It is critical that we give VA the tools529it needs to succeed, and with Congress's help, VA has made530progress in recent years to reduce over prescriptions, improve531oversight, embrace innovation, and strengthen its mental532healthcare system. We are hopeful that the challenges being533discussed today will be the focus of even more effort to ensure534that veterans receive the best possible support when seeking535mental health care.536    Thank you for this invitation to testify and I welcome your537questions.538539    [The prepared statement of Dr. Fletcher appears on pages54063-70 of the Appendix.]541542    Chairman Moran. Thank you very much.543    Before we go to questions, let me turn to the Ranking544Member Senator Blumenthal for his opening statement.545546                    HON. RICHARD BLUMENTHAL,547         RANKING MEMBER, U.S. SENATOR FROM CONNECTICUT548549    Senator Blumenthal. Thank you. Thank you, Mr. Chairman, and550my apologies for my lateness. I'm going to put my statement in551the record. But let me just thank you and thank the witnesses552for being here today.553554    [The opening statement of Senator Blumenthal appears on555pages 31-33 of the Appendix.]556557    Polypharmacy often is a symptom of long wait times for care558or other factors that may result in multiple medications that559conflict with each other or cause damage to the individual.560Insufficient clinical capacity, fragmented care and lack of561accessible alternatives to medication may lead to overreliance562or mismanagement of pharmaceuticals. And unfortunately, what563we've seen is longer waiting times for access to care.564    Reports indicate that there is a serious deviation from565VA's commitment to evidence-based veteran-centered mental566healthcare. And I have written to Secretary Collins about it.567I'm going to put that letter in the record as well.568569    [The letter referred to appears on pages 87-88 of the570Appendix.]571572    The VA has lost a lot of its staff, which could account for573those delays, and it needs to be in the position to have the574resources to restore its mental health care network. And let me575just say finally, by way of this introductory statement that,576Dr. Fletcher, I was concerned that the VA has instituted a577copayment for holistic treatment like yoga, fitness classes,578meditation, whole health coaching that allow veterans to rely579on treatment other than just medication. And I think that is580really counterproductive.581    So, I look forward to our questions and again, my thanks,582Mr. Chairman.583    Chairman Moran. You're welcome, Senator Blumenthal. Let me584begin with a broad question to each of you. In part, what585precipitated this hearing was the reporting from The Wall586Street Journal that highlighted troubling examples of veteran587medication experiences. From each of your perspectives, how588closely do those cases align with what your office or589organization is seeing and where do they differ?590    In other words, tell me whether what you see is what is591reported in that article and what we should know about that.592Start with you, Ms. Hundrup.593    Ms. Hundrup. Thank you. So, in our work, we had found594there's a number of factors that influence providers' decisions595to prescribe. They ranged from the resources at a medical596center, to complexity of the conditions, the comfort level with597prescribing, as well as the availability and the types of598treatment. So there's really a lot that can influence it.599    At the time of our work, which was based on fiscal year6002018 data, so it's a little bit dated, there were 37 percent of601veterans with at least one mental health condition that were602prescribed a psychiatric medication, either alone or in603combination with therapy. And focusing on those with PTSD,604veterans taking two or more classes of medications ranged from60532 percent for those seeing a primary care provider to upwards606of 61 percent for those seeing both primary and specialty care607providers.608    Now, as has been stated, polypharmacy in and of itself609isn't necessarily problematic. So in preparation for this610hearing, we were looking to see if there was updated data on611where the VA is in terms of polypharmacy. Again, not to say612that polypharmacy alone is bad, but it does increase risks.613Updated data were not available. So I would encourage the VA to614make those data available and it is worth examination.615    What we did recommend is making sure the treatment plans616have clear identifiable information so that they can monitor617that and see where there are risks and mitigate those risks,618such as if a provider is doing a lot of prescribing and you see619a lot happening, you can look into that and see if that is620appropriate to make sure that they're mitigating any risks or621taking action if that may be the case.622    Chairman Moran. Is that a suggestion so that we could623compare what takes place at the VA with other healthcare624providers?625    Ms. Hundrup. Well, just to have a number to update where we626are, you know, a lot has changed since 2018. So just to627understand veterans, for example, with PTSD or other mental628health conditions, what kinds of prescribing is occurring, what629kinds of classes of psychiatric medications are they getting?630For a while there was a lot of concern about opioids in631combination with benzodiazepines. I know that had been reduced632greatly and that was something that the VA made great strides633in. But where are we today? Has that continued to decrease? I634think some of these allegations in the article, we just don't635have the data, so we don't know. So I think the first order of636business is really seeing updated data.637    Chairman Moran. Fresh data. Okay, thank you. Doctor,638anything to add or suggest?639    Dr. Kroviak. I was actually quite disappointed in the640article. I think it is devastating to read about the patient641experiences. Those are real. Yes, I found the article642disappointing. The cases were devastating. The patient643experiences are real. But what I didn't, and I wouldn't expect644to have seen in the article is what the medical record showed,645what the provider and healthcare team, what their response646would've been, and how they supported the patient. These were647complicated patients. It's easy to understand that from reading648the article, that VA treats very complicated patients.649    I was also very disappointed that the suggestion is that650the VA providers are handing out medications to avoid providing651adequate care. That's not what we've seen. We've been in every652facility, CBOC, Vet Center, CLC; this is not what we're seeing.653We are seeing compassionate, dedicated providers managing654incredibly complicated patients.655    Chairman Moran. Great to hear. Thank you. Dr. Fletcher?656    Dr. Fletcher. Yes. Thank you for the opportunity. So what657we hear from the warriors we serve is that they often encounter658medication recommendations before therapy is offered or even659accessible. And so we know this doesn't happen everywhere, but660we've heard it consistently enough that it suggests an661opportunity to increase access to first line psychotherapies662and more shared decision-making in the treatment planning663process.664    Chairman Moran. Is what you're saying different than what665Dr. Kroviak was saying?666    Dr. Fletcher. No, I think there's a lot of similarities. A667lot of similarities, yes.668    Chairman Moran. Senator Blumenthal.669    Senator Blumenthal. Thank you. Dr. Fletcher, to what extent670have waiting times for mental health appointments been due to671diminished staff, and I'll ask the same question of our other672witnesses as well?673    Dr. Fletcher. Thank you for that question. So what we've674heard, again, from the warriors we serve is that they are675experiencing access to care difficulties and that can create676problems. We know that warriors with the best outcomes have677access to evidence-based treatment, are well-informed about the678medications that they are taking, and again, are active679participants in the treatment planning process.680    Senator Blumenthal. Dr. Kroviak?681    Dr. Kroviak. Yes, we are aware of shortages in mental682health providers and access to care within mental health and683health in VA. That's not unique to the VA healthcare system.684So, the wait times we're seeing in VA are also reflected in the685wait times that veterans are experiencing when being referred686to the community. So, it is a much bigger problem than just VA.687    Senator Blumenthal. It's not unique. But what is maybe688unique, certainly unusual to the VA healthcare system, is that689it is discouraging talented mental health professionals from690coming to the VA through policies of furloughs and firings.691Would you agree?692    Dr. Kroviak. So, I will say through our cyclical reviews,693where we go out to facilities not for cause, but to try to get694a feel for culture and quality of care practices, we are695getting more feedback that morale is going down because of the696uncertainty within the Federal Government. So yes, while they697aren't participating in the DRP or didn't participate in the698DRP or other programs, clinical staff were exempted from that,699but they are still losing clinical staff because of morale.700    Senator Blumenthal. Morale going down means----701    Dr. Kroviak. Correct.702    Senator Blumenthal [continuing]. That fewer talented and703skilled professionals are going to come to the VA or stay,704they're going to be leaving if morale----705    Dr. Kroviak. Yes, I have to say, these are discussions we706have with leaders. We are not asking them to validate the707data--they're just sharing in a conversation the concerns at708the local level.709    Senator Blumenthal. Did you have anything, Ms. Hundrup?710    Ms. Hundrup. I would just quickly echo what Dr. Kroviak711said about the nationwide shortages applying to both VA and712inside as well as outside. Also, it is important to distinguish713between care within VA and outside care. For the VA, there is a714timeliness standard for care in a VA facility. They don't have715that for receiving care in the community, which means that VA716is limited in its understanding of how long it's taking for a717veteran to be seen in the community or what the challenges are718or how best to address them.719    And we do have an outstanding recommendation for VA to720establish a timeliness standard, which would help give us more721information about the differences. And of course, timeliness of722care is an access to care issue because the longer a veteran723has to wait can exacerbate health issues. Thank you.724    Senator Blumenthal. And of course, The Wall Street Journal725article the Chairman referred to a little while ago, ``Combat726Cocktail: How America Overmedicates its Veterans'', I think727indicates that the care for them, mental health care or other728kinds of care is really important to prevent the overmedication729that often results from the cocktail of pharmaceutical drugs730that may be prescribed sometimes wrongly or inadvertently. And731I wonder if you can say Dr. Fletcher, whether there should be732stronger safeguards oversight to prevent that kind of problem?733    Dr. Fletcher. I thank you for that. What we hear from our734warriors is that they want to spend more time with their735providers. They want to fully, you know, process through their736trauma, their symptoms. They want to be informed about the737medications that they're being prescribed. We know that738consistent follow-up increases chances of treatment adherence739and treatment compliance. Consistent follow-up allows providers740and veterans to identify medications that may not be working741properly, avoid symptoms, you know, side effects that become742too uncomfortable. That consistent oversight is important to743successful clinical outcomes.744    Senator Blumenthal. Well, again, my time is about to745expire. Let me just say that I appreciated both the OIG and the746GAO findings, which I think are tremendously important. Just as747one example, 33 percent of VHA facilities were not in full748compliance with requirements to have a pain management team.749That seems like a really basic failing. And again, you can't750have pain management without the personnel to do it. And I751think unfortunately, the VA is sacrificing that tremendously752important capability. Thank you, Mr. Chairman.753    Chairman Moran. Senator Tuberville.754755                     HON. TOMMY TUBERVILLE,756                   U.S. SENATOR FROM ALABAMA757758    Senator Tuberville. Thank you, Mr. Chairman. Thanks for759being here. Good to see you all. Very important issue. We have760a lot of problems in my State of Alabama with overprescribing761at times. Doctor, you and Ms. Hundrup spoke about enhancing762oversight at the VA and medical management related issues,763especially a better hold on medical professionals accountable764for overprescribing harmful medications. Do we have a plan for765that? Both of you, could you all answer?766    Dr. Kroviak. So, ultimately, the plan is VA's, but what our767oversight work has shown that a lot of critical leaders in the768VISN, which is a body that exists to oversee the facilities, do769not have defined roles, and responsibilities, and clear lines770of authority. So, VA has a plethora of directives and policies771that, you know, are based in evidence.772    However, it's the consistent application of those policies773and practices where we find most of the issues that we report774on. With structured oversight roles within the VISN, where775leaders know what is their responsibility, it is written down776and they own it, and that certain staff and procedures and777practices, they are accountable to that leader can really help778enforce--we feel it could really help enforce the more779consistent application of these directives and policies and780practices that they have plenty of.781    Senator Tuberville. Thank you. Ms. Hundrup?782    Ms. Hundrup. I would also, again, echo Dr. Kroviak. I think783we have many similar findings and share the same sentiments,784but I would just add that in our work, I think by having VA785more clearly document the treatment plans that are in a mental786health care plan and have them be easily identifiable as well787as document what evidence-based treatment options were788considered. Obviously, in many, many cases it's very complex.789There's not a straightforward answer.790    There does have to be adjustments very specific to the791individual that change over time. And these are complex cases,792so you might have multiple medications involved. But by having793that documented and clear in the record, it sets up VA to be in794a position to monitor that. And they had committed to reviewing795individual providers' plans, you know, a sample of plans on a796biannual basis just to make sure. I think as Dr. Kroviak said,797some of the policies are only as good as they're implemented.798    So, you know, I would be interested to see what VA is doing799to continue to monitor and look for outliers and then take800action with providers that may not have the best education or801may not be making the best decisions for their veterans.802    Senator Tuberville. Do you all think we should have803oversight on foreign manufactured drugs that we give our804veterans? Is there any thought on that?805    Dr. Fletcher. Thank you for that question. I think where806the Warrior Project we stand on this is, we want our veterans807to be as informed as possible about the medications that808they're taking. We want treatment recommendations to evidence-809based research informed and prescribed in the safest manner810possible.811    Dr. Kroviak. I don't have a specific comment on the812oversight. You said meds manufactured over----813    Senator Tuberville. Foreign manufactured.814    Dr. Kroviak. Yes, I mean, again----815    Senator Tuberville. Which most of them are by the way816anyway, I would think.817    Dr. Kroviak. Right. I mean, this whole medication818reconciliation process that I've emphasized in my testimony is819really more about the interaction between the prescriber, the820provider, and the patient. I think that's where all of this821sort of action has to happen to where everybody's on the same822page. It's really outside of the VA to where the question823you're asking would be, you know, put into play and absolutely824I would not, you know, speak against increased scrutiny over825the safety of the medications that we're buying and826prescribing.827    Ms. Hundrup. I would just echo that. That's not something828that I have familiarity with, but I think that's an important829topic that VA should be closely looking at.830    Senator Tuberville. Thank you. I got 45 seconds. Ms.831Fletcher, I hosted a field hearing in Montevallo, Alabama this832spring talking about HBOT and psychedelic-assisted therapy. Do833you think that expanded access through FDA approval of these834types of therapies could and would help address the835polypharmacy issue?836    Dr. Fletcher. Thank you for that question. I think that837access and research into alternative treatments is something838that a lot of the warriors that we serve would be interested839in. We hear oftentimes that they're coming to us saying that840they've tried more traditional therapies and are more eager to841pursue the non-traditional therapies when they haven't found842that success. But again, we would want these treatment843recommendations to again, be based on patient safety and844evidence-informed.845    Senator Tuberville. Thank you. Thank you, Mr. Chairman.846    Chairman Moran. Senator Hirono.847848                     HON. MAZIE K. HIRONO,849                    U.S. SENATOR FROM HAWAII850851    Senator Hirono. Thank you, Mr. Chairman. Thank you very852much for the panel. So, we have millions of veterans, millions853of veterans, and a rather large percentage of them have PTSD.854And according to The Wall Street Journal article, nearly 60855percent of VA patients with PTSD, and I don't know what that856translates to into numbers, but they say that's over half a857million patients. Are each of these veterans with PTSD supposed858to have an individual treatment plan? I don't know who to ask859this question to. Yes? No?860    Dr. Fletcher. Yes. I think that having an individualized861approach to treatment yields better outcomes.862    Senator Hirono. I know. That's not my question, though. Do863each of these, over half a million, let's just focus on the864veterans with PTSD, do they each have a treatment plan and865who's supposed to come up with a treatment plan for each of866those veterans?867    Dr. Kroviak. If they're diagnosed with PTSD and being868treated, then they are required to have a treatment plan that869is created and monitored by their healthcare team.870    Senator Hirono. And Dr. Fletcher, you deal directly with871the veterans of the two other panel members. So, do they have872individualized treatment plans?873    Dr. Fletcher. I would say that that varies across veterans874and across----875    Senator Hirono. I'm sorry, what?876    Dr. Fletcher. I would say that that varies. I can't speak877necessarily for all of the veterans. We typically hear that878when they're afforded the opportunity to have the access to879this evidence-based treatment that it can be individualized,880but it's not always.881    Senator Hirono. Well, when you think about the number of882veterans we have and their medical needs and they go to VA,883it's just astronomical. The needs are astronomical. And at a884time when there have been pretty significant cuts to VA, which885always had a shortage of providers. Isn't that true? I mean, in886Hawaii they're always trying to hire people for the VA. So,887there's always been a shortage. It's been exacerbated with this888regime. Isn't that so? That shortage? Somebody?889    Dr. Kroviak. So, the OIG publishes a report annually on890critical staffing shortages, and for the past 8 to 10 years, I891can't remember exactly, but this year, yes, you are correct.892We've noticed the most significant increases in those----893    Senator Hirono. So, at the same time as, I think Dr.894Fletcher, no--GAO, I think you said that there needs to be yes,895more oversight. And when you have the staffing cuts, etc.,896who's supposed to provide the oversight that you are897recommending? This is for Ms. Hundrup, am I pronouncing your898name correct?899    Ms. Hundrup. Yes, that's correct.900    Senator Hirono. So, you say more oversight is needed, but901there are massive cuts to VA. Who's supposed to provide the902oversight for the medical care of the veterans?903    Ms. Hundrup. Right. I think that that's where there is a904level of oversight to ensure, because as I mentioned, if you905have a policy or requirement, it's only as good as----906    Senator Hirono. But do we? You're saying that they need907more oversight, but there isn't more oversight. In fact, I908would say there's less, because there are cuts. There have been909cuts to the VA's capacity to provide care. So, what I'm seeing910is that I commend you all for pointing out the needs, but how911are the needs supposed to be met when the VA is actually making912pretty significant cuts to an already strapped healthcare913system, the biggest healthcare system in the country? I mean, I914don't know how the veterans are supposed to receive the kind of915care they need when there are cuts to the provider base.916    Ms. Fletcher, I was intrigued by your saying that veterans917would like to have alternative kinds of care, and is that a918fruitful avenue for us to support and pursue if we're not going919to have all the mental health providers that are necessary, you920know, non-traditional services? Are we doing something to921provide those kinds of programs?922    Dr. Fletcher. I think that there is absolute value in923pursuing research to support these alternative therapies. What924we've typically heard, again, is most of the warriors that we925serve are willing to avail themselves to the frontline926treatments that are already available. What we hear is they927seek these alternative therapies when what they've tried hasn't928worked. And we always want--and so a commitment to innovation929in mental health care is absolutely needed.930    Senator Hirono. Do you think that that is a fruitful way to931go, but because the VA system lacks providers, especially I932would say mental health providers, maybe primary care933providers, but if we can create an environment where934alternative kinds of support can be provided, is that a935fruitful way for us to proceed? Dr. Fletcher?936    Dr. Fletcher. Yes, I do believe there's value in pursuing937alternative therapies.938    Senator Hirono. Well, that may be one of the ways to go939when we lack resources. Thank you, Mr. Chairman.940    Chairman Moran. You're welcome. Senator Sheehy.941942                        HON. TIM SHEEHY,943                   U.S. SENATOR FROM MONTANA944945    Senator Sheehy. Thank you all for coming today. Appreciate946your commitment to this important cause. As a combat veteran947myself, married to a combat veteran, I take very personal stake948in all these matters and thank you for your commitment to the949cause. You know, I think to respond to some of my colleagues'950comments there, all the more reason why the community care951model was introduced and is more critical now than ever, which952is the VA has perpetually been underresourced especially in953rural states like Montana, where you cannot have a VA clinic in954every town.955    And when most towns are two to three hours apart, when it's956a five-hour drive, from Plentywood to Helena, the expectation957that a VA clinic will be available within reasonable driving958distance in a negative 30-degree snowstorm, is unlikely. And959taking advantage of the community care options and investing in960community care, especially in our rural states, is just as961important now more than ever.962    You made a great point today Dr. Fletcher, and I want to963reinforce, and that's the alternative care model. That we're964seeing so many veterans now flying to Mexico, flying to the965Middle East, going to Turkey to get psychedelic treatment. That966they're finding immediate relief from PTSD, from TBI. They're967finding it to be safer, healthier, and far more effective for968them and their families. And yet that type of treatment is not969only not provided by the VA or our healthcare system at all,970it's been stigmatized and in some cases treated as illegal,971even though it's working far better.972    And I think whether it's acupuncture or dry needling or973yoga, meditation, sleep therapy, or alternative psychedelics,974we need to be open-minded about how we can adopt these975therapies. And unfortunately, this isn't a knock on the VA, but976the government is not inherently going to be an innovative,977entrepreneurial, creative place. It's just not. It's opposed to978the DNA of a government bureaucracy. And we shouldn't fight979that. We should welcome that and say, outside groups like980Wounded Warrior Project, like other nonprofit organizations can981be those hotbeds of innovation.982    And we should be able to welcome those in and welcome their983creative thought process. Because at the end of the day, it's984about the outcomes, not the process. Veterans not victims,985patients not bureaucracy, and outcomes over process. And at the986end of the day, that's what we have to focus on. So, thanks for987your comments there.988    Ms. Hundrup, I want to go back to a comment you made, I989think it was incredibly relevant. I'd like your thoughts on990that. You said, you know, no matter what the legislation or the991policies are, if they're not executed properly, none of that992matters. And I think that that is government in a nutshell at993the end of the day. We can all pass laws, but if the people994that we employ to enact those policies aren't the right ones or995are not doing it properly, it's going to fail.996    This written informed consent law we're trying to pass, I997think has broad support across the veteran, the nonprofit, and998the healthcare industries, and in communities. I'd like your999thought on should this pass, how we ensure that when it passes,1000if it passes, we enact it properly, and the outcome is what we1001want?1002    Ms. Hundrup. Yes. I think informed consent is important1003because it's an explicit way to ensure the patient knows about1004the risks of the medications they may be taking. In the case of1005the Opioid Safety Initiative, we did find that the informed1006consent was lacking and recommended that VA take steps. In1007implementing our recommendation, they implemented a tool so in1008the medical record, there's a flag to show whether or not1009informed consent for long-term opioid therapy was discussed and1010signed by the patient.1011    So, I would suggest perhaps a similar approach where in1012that medical record, if it is expanded to other psychiatric or1013other medications for informed consent, there could be a1014similar flag that in prescribing it, it blips up on the medical1015record and they can then have that discussion with the patient,1016including the date that that was had.1017    Senator Sheehy. Do you feel the VA is currently structured1018to be able to effectively implement this rule should we pass1019it?1020    Ms. Hundrup. I will acknowledge it's been a while since we1021looked at this, but I understand that tool was in place in1022their medical records. Now, I will acknowledge a lot is1023happening with the medical records right now and the1024transition. But should what we understood to take place when1025they implemented our recommendation in 2020 still be there and1026still be utilized. I think it's worth asking.1027    I think my understanding is it could be a simple process to1028add that and that providers would be continuing to do that.1029I've not heard any cases where it has been lacking, but again,1030it's up to each provider in that medical record to document1031that for that individual veteran.1032    Senator Sheehy. Now on its face, unrelated, but all things1033relate to this, do you think this is yet another reason why we1034must reemphasize electronic health records, linking DoD health1035records that have a seamless pass through to VA health records1036so we do not have to continue to waste billions of dollars in1037years and lives losing medical records from years in service,1038from combat injuries that have been meticulously documented by1039the DoD, and then we throw them in the trash and rebuild them1040from scratch for the VA, which takes years, missing treatments,1041missing symptoms, and failing our veterans.1042    Is it finally time for us to have a DoD to VA health record1043that is seamless and there's no delay and there's no ledge that1044people fall off of?1045    Ms. Hundrup. Absolutely.1046    Senator Sheehy. Thank you.1047    Chairman Moran. Senator Sheehy, you might want to tell our1048colleagues about the plan for a roundtable that you've asked me1049to conduct to have a conversation about a topic that you1050described in some of your questioning. So, next Tuesday at 21051o'clock, you might tell us what you have in mind.1052    Senator Sheehy. Thank you, Chairman. Yes, we're going to1053talk about our alternative treatment ecosystem. After I was1054wounded, I was privileged to undergo some processes at Walter1055Reed, which were eye-opening for me. A lot of the alternative1056treatments that we've talked about: psychedelics, sleep1057therapy, yoga, etc. But specifically, the availability of1058psychedelics and how we can bring those into the VA system,1059into the broader veteran healthcare ecosystem as we're seeing1060really a tremendous caseload of feedback from veterans and1061patients who've benefited from that treatment, very1062specifically, and come back and testify that these treatments1063are having an incredible impact on them, and the side effects,1064at least so far are minimal to negligible.1065    So, thank you for giving me an opportunity to bring that1066up. It's going to be hopefully, a pretty insightful session.1067Thank you.1068    Chairman Moran. You're welcome. Thank you for your1069leadership and interest in this topic and Committee. We have1070not invited every Committee member, but you're all invited. We1071invited everybody who's on this Committee that has been engaged1072in this psychedelic treatment aspect of pursuing policy, but1073anybody and all are welcome to come and it's next Tuesday at 21074o'clock.1075    Now, Senator King.10761077                    HON. ANGUS S. KING, JR.,1078                    U.S. SENATOR FROM MAINE10791080    Senator King. Thank you, Mr. Chairman. I want to emphasize1081what Senator Sheehy just said. As I looked over my notes and my1082questions, it all comes back to decent electronic medical1083records. You talked about coordination with community care,1084good electronic medical records, coordination with veterans1085coming out of the Defense department, decent electronic medical1086records. And everything comes back to that.1087    I mean, the overprescribing or prescribing polypharmacy1088where there's conflicts and danger, that's where you get--that1089won't happen if you have decent medical records. So, every1090practitioner that sees a veteran sees the same information1091about what they're taking, what they've been prescribed, what1092their history is, all that necessary background.1093    So, the development of electronic medical records for the1094Department of Defense and the VA has been an absolute debacle.1095And we're spending billions of dollars, it's still not working.1096It's been tested. People don't like it. I've never understood,1097frankly, why we didn't use the same system that's already on1098the shelf for thousands of hospitals across the country. Why1099are we inventing a whole new system for these patients? But1100sorry about the speech, but Senator Sheehy provoked it, because1101he's absolutely right.1102    A personal story. Just recently, I talked to an elderly1103friend, and in our conversation, I realized that she was much1104sharper and more engaged and with it than had been the case1105just a month or two before. And I didn't really think too much1106about it until I later talked to her husband who said she had a1107fall, she had a broken knee, she went into the hospital, her1108physicians looked at her prescription record and changed the1109prescriptions, and she's a different person.1110    Nothing else happened other than taking her off certain1111drugs, putting her on others, and adjusting the volume, if you1112will. And so this was totally obvious, and all it was, was1113somebody seeing cohesively what the prescription record was.1114And I'm sure that's happening with thousands of veterans.1115    One question I have is, this seems to be a prime area where1116AI could help. AI could tell you whether there are1117contradictions and problems. I mean, I think that's one area.1118Everybody's talking about AI and all the problems. But this is1119something where AI could quickly and instantly analyze. It1120would have every drug in the world and you put in, ``What would1121happen if this person is taking these three drugs and I1122prescribe this?'' It would give you an instant answer. Isn't1123that true? You're nodding. Nodding doesn't show up in the1124record. You have to say, ``Yes, Senator. That was a brilliant1125comment.''1126    [Laughter.]1127    Ms. Hundrup. Yes, Senator. That is not a topic we've looked1128at in-depth, but I do think you're absolutely right. And in1129terms of just even some of the record sharing, we do understand1130from VA in terms of them stating their intent to implement our1131recommendations that they do anticipate using medical1132technologies like AI. So, I think just to loop back to the need1133for oversight and the need for more people, I do think there is1134promise that AI could alleviate some of that.1135    We're very early, and that's not something that GAO has1136looked at specifically, so I need to stop there, but I think it1137has a lot of promise.1138    Senator King. One of my questions is, is there any part of1139the VA routine that involves an annual checkup of your1140medications? Is that something the VA does routinely? It seems1141to me that would be a useful tool.1142    Dr. Kroviak. I can take that question. So, within an EHR,1143including the old CPRS that VA uses and the new Cerner record,1144when you prescribe a new medication, the software itself is1145taking that one medication against the list of medications a1146patient is already prescribed or against a known list of1147allergies the patient has reported.1148    So, what you're saying is happening in even the most basic1149EHR function. The issue is an alert can pop up that describes1150the risk level of that interaction. So, the provider in that1151moment has to make a determination like, ``Yes, I know this1152risk exists, but I'm taking the risk because it's worth1153whatever outcome or treatment plan I've established.'' So, what1154you're saying is happening. It doesn't require new technology.1155    Senator King. There are regular reviews of medication?1156    Dr. Kroviak. Every time you see a patient, this medication1157reconciliation process should be happening between provider and1158patient, but the software that they're using when you enter a1159new medication will run it against the inventory of what's1160already being prescribed to make sure those interactions aren't1161happening that you're worried about.1162    Senator King. And one of the things you mentioned was the1163possible lack of communication and coordination with community1164care?1165    Dr. Kroviak. Yes.1166    Senator King. That's correct? So, that's a gap we should be1167paying attention to?1168    Dr. Kroviak. It's a massive gap that we've reported on1169frequently. There is a technological solution--one day when all1170EHRs communicate with each other. That's the ultimate solution.1171We are nowhere near that.1172    Senator King. And there's no excuse for being nowhere near1173that in this day and age. But I deeply appreciate your1174testimony and I hope you'll follow-up as a result of our1175questions and what the Committee is after. Let us know what we1176can do to help. That's our job here. And you can be our eyes1177and ears in the field and say, ``Here's a gap. Here's a1178problem. Here's where either oversight by this Committee or1179legislation by this Committee could help to fill those kinds of1180gaps.''1181    Thank you very much for your testimony. Thank you, Mr.1182Chairman.1183    Chairman Moran. Senator Hassan.11841185                   HON. MARGARET WOOD HASSAN,1186                U.S. SENATOR FROM NEW HAMPSHIRE11871188    Senator Hassan. Well, thanks, Mr. Chairman and Ranking1189Member Blumenthal. And to our witnesses, thank you for your1190support of veterans.1191    Ms. Hundrup, I wanted to start with you. As you highlighted1192in your testimony, veterans often experience hardships in the1193transition period where they leave the military and reenter1194civilian life. As you know, the GAO recommended that the DoD1195and VA's Joint Executive Committee, which oversees the1196coordination of healthcare and benefits between the military1197and the VA, assess the effectiveness of DoDs and VA's efforts1198to facilitate access to mental health services for these1199transitioning service members.1200    So, can you discuss why it's important to make these kinds1201of assessments and how they can help lead to potentially1202improving the healthcare that our veterans are receiving during1203this critical time?1204    Ms. Hundrup. Yes, thank you. So, in our work, we identified1205a number of helpful touchpoints across the transition1206continuum, which is 1 year before separation to 1 year after.1207However, there was often some confusion about which program1208they need to use or how it works. Sometimes a lack of1209awareness. Some of the programs we found were late. So, for1210example, there were two programs, Solid Start and inTransition,1211both noble programs with good intent, but they were identifying1212the veterans two to three months after separation, which is1213already very late in the process.1214    Senator Hassan. Yes.1215    Ms. Hundrup. And there was also potential duplication1216getting similar phone calls, which was just resulting in1217confusion on the part of the veteran maybe being overwhelmed,1218not knowing. So, not only was it late in the process, but1219looking across, there are a lot of different programs. I think1220each individually has, again, noble goals and provides critical1221services. But looking across, there was, you know, maybe some1222places that were a little too late.1223    Senator Hassan. But as we look at assessing this,1224especially for mental health care, what is the value of this1225assessment in terms of mental health access?1226    Ms. Hundrup. So, the value of this assessment will be to1227look across and identify the timing, whether there are gaps,1228whether certain things could be done earlier, whether, for1229instance, the Separation Health Assessment is supposed to have1230a mental health assessment that's not happening now.1231    So, I think they could identify what is happening, where1232there are gaps, maybe there's overlap or duplication, and1233really look systematically across, which I think could result1234in some savings on the part of DoD or VA or both. And they can1235take those savings and shift them. So, services really coming1236at the right time in a clear manner for the veteran that are1237more understandable. So, I think it's going to result in a more1238cohesive, holistic approach.1239    Senator Hassan. And I think that's, you know, critically1240important, as somebody who advocated it and worked on the Solid1241Start Program. The idea was day one of the transition, there1242would be these things in place, right? And that means that the1243organizations have to start planning before the veteran1244separates.1245    Dr. Kroviak, let me kind of follow up in a way on what1246Senator King was just talking about, because one of the issues1247you've raised is medication management for veterans who are1248receiving community care. And you've discussed, it's really1249important that veterans who receive community care have their1250opioid prescriptions coordinated and monitored by the VA. The1251coordination and oversight obviously can be lifesaving for1252veterans struggling with pain and mental health conditions.1253    In 2023, the Inspector General's office looked into VA1254oversight of community care opioid prescriptions and found,1255``Gaps in care coordination documentation and the use of risk1256mitigation strategies for system patients receiving community1257care.'' In your testimony, you stated that two of the seven1258recommendations from that 2023 report still haven't been1259implemented.1260    So, what problems remain in terms of ensuring the community1261care providers and the VA are working together to ensure that1262veterans, especially those who are being prescribed opioids,1263are getting the safest, best care that they can, and what can1264we do in Congress to help?1265    Dr. Kroviak. Yes, so I think those two recommendations1266you're referencing are specific to that information sharing.1267And we have been working with IVC, which is the Integrated1268Veteran Care program office that runs community care. It is a1269struggle to ensure that communication and oversight of that1270effective sharing of information, and it will require likely1271changes to the contract, modifications to the contract that VA1272has with the TPAs currently. They are up to renew that contract1273in the coming year. They're taking our considerations and1274concerns very seriously, and we meet with them quarterly to1275discuss how we can move forward with ensuring these things1276happen.1277    Senator Hassan. Well, let us know if we can be helpful in1278that way and urging forward.1279    Dr. Kroviak. Of course. Thank you.1280    Senator Hassan. I'm just about out of time, so I'll follow1281up in writing, but I continue to be really concerned about the1282issue of veterans, especially with mental health issues being1283given the right kind of follow up instructions about their1284medications when they're discharged. So, I'll follow up with a1285question in writing for you on that. Thanks, Mr. Chair.1286    Chairman Moran. Senator Hassan, thank you.1287    We have another panel and we have not yet called the 4:301288vote, so we might be in good shape for the hearing to conclude.1289I'll quit talking to improve the chances, except I don't have1290time to ask these questions. But I'm very interested, Dr.1291Kroviak, in community care. And it seems like other Members of1292this Committee are. I don't know whether the problem--I1293suppose, because we don't have the information, the1294coordination. We don't know whether there has been real life1295problems for the veterans or whether it's lack of ability to1296demonstrate whether that exists or not.1297    So, I'll follow up with my staff and you to have that1298conversation like, are veterans at real risk or we don't know.1299And it's not just a paperwork issue, I don't mean just, because1300records are important, information matters. And I'm interested,1301of course, in the Eastern Kansas report that you alluded to and1302want to hear more about that.1303    And then I think it was you, Dr. Fletcher, that maybe said1304something about prescription first image. I want to know1305whether the prescription first image has a basis in fact, or1306whether it's just something that is said. And then also there1307is an impression that the VA has been successful in1308overprescribing opioids and I'd like to know the facts about1309that belief.1310    And so those are the things I want to follow up and I'll1311ask my staff and you to have those conversations. I thank you.1312I knew if I did this, that Senator Blumenthal would think he1313was entitled as well [laughter].1314    Senator Blumenthal. Just a really quick question which I1315neglected to ask before, Ms. Hundrup. The Wall Street Journal1316article says, ``Only 15 percent of veterans diagnosed with1317depression, PTSD, or anxiety are offered psychotherapy in lieu1318of medication according to a 2019 report by the Government1319Accountability Office.'' Is that percentage still accurate?1320    Ms. Hundrup. Unfortunately, I don't have updated data on1321where we are with that, which is to my earlier point, as I1322think it's worth following up with VA since publicly available1323data on that are not out there.1324    Senator Blumenthal. If you could follow up, I would1325appreciate it. But you know of no reason that that number has1326changed?1327    Ms. Hundrup. I don't know that that would necessarily1328change, no.1329    Senator Blumenthal. Thank you. Thanks Mr. Chairman.1330    Chairman Moran. Senator Blumenthal, thank you. Thank you1331all very much for your testimony. Appreciate your commitment to1332this cause. And with that you are dismissed, quickly. And I1333welcome our second panel, quickly.1334    Testifying today on the second panel is Dr. Ilse Wiechers,1335Deputy Director, Office of Mental Health, U.S. Department of1336Veterans Affairs, and she is accompanied by Tom Emmendorfer,1337Executive Director of Pharmacy Benefits Management, U.S.1338Department of Veterans Affairs.1339    Thank you both very much for your presence and Dr.1340Wiechers, you are recognized for your testimony.13411342                            PANEL II13431344                              ----------13451346    STATEMENT OF ILSE WIECHERS, MD, MPP, MHS, ACTING DEPUTY1347ASSISTANT UNDER SECRETARY FOR HEALTH FOR PATIENT CARE SERVICES,1348  VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS1349AFFAIRS ACCOMPANIED BY THOMAS EMMENDORFER, PHARM.D., EXECUTIVE1350     DIRECTOR, PHARMACY BENEFITS MANAGEMENT (PBM) SERVICES13511352    Dr. Wiechers. Good afternoon, Chairman Moran, Ranking1353Member Blumenthal, and Members of the Committee. I am Dr. Ilse1354Wiechers, Acting Deputy Assistant Under Secretary for Health1355for Patient Care Services at the Veterans Health1356Administration. I'm joined today by Dr. Tom Emmendorfer,1357Executive Director of Pharmacy Benefits Management Services.1358Thank you for the opportunity to speak with you about how VA1359ensures safe, effective, and veteran-centered medication1360management, and to share our views on the three bills under1361consideration today.1362    As a practicing VA psychiatrist for over 15 years now, I'm1363aware of the complexity of medication management for our1364Nation's veterans. Many veterans live with multiple chronic1365conditions like PTSD, chronic pain, and substance use1366disorders, which often require complex treatment plans.1367    While multiple medications may be necessary, we recognize1368the risks of polypharmacy and are committed to reducing1369unnecessary or unsafe prescribing. VA has built a strong1370foundation for safe medication use through our national1371formulary and evidence-based prescribing practices. We use real1372world data, not market incentives to guide decisions.1373    One example is our use of pharmacogenomics, which helps1374tailor medications to a veteran's genetic profile. This1375approach is improving outcomes in reducing adverse drug events.1376We have also made significant progress in opioid safety. Since1377launching our Opioid Safety Initiative in 2013, we have reduced1378opioid prescribing by 68 percent and cut concurrent opioid and1379benzodiazepine prescribing by 90 percent.1380    Tools like the STORM--Stratification Tool for Opioid Risk1381Mitigation--dashboard help us identify veterans at high risk1382and coordinate care to prevent overdoses. VA has continued to1383make it easier for veterans to obtain the life-saving1384medication Naloxone. We distribute Naloxone widely: over 1.81385million prescriptions to date, as well as providing overdose1386education to veterans and the caregivers. Naloxone is available1387free of charge to enrolled veterans in various forms. It can be1388accessed through VA pharmacies, mobile units, community events,1389and even by messaging care teams through the VA app or website.1390    In addition, we are continuing to advance the Psychotropic1391Drug Safety Initiative or PDSI, a decade long quality1392improvement effort focused on safer prescribing of medications1393for mental health conditions. PDSI has helped reduce1394inappropriate use of benzodiazepines and anti-psychotics,1395especially among veterans with PTSD and substance use disorder.1396    Despite these successful initiatives, we acknowledge there1397is more work to be done. That's why VA recently issued a1398request for information to identify innovative software1399solutions that can support individualized medication review and1400de-prescribing. This is part of our broader effort to address1401polypharmacy and ensure that every medication has a clear1402evidence-based purpose.1403    Now, I will turn briefly to the legislation before the1404Committee noting that our full views are detailed in my written1405statement. VA supports the End Veterans Overdose Act subject to1406amendments. We agree with the goal of expanding access to1407Naloxone, but we are concerned about removing prescription1408requirements entirely. Prescriptions help ensure accountability1409and stewardship of government resources. That said, we've1410already taken steps to make Naloxone widely accessible,1411including permitting the use of standing orders or1412prescriptions for any veterans at risk of overdose. We remain1413committed to increasing the availability of overdose reversal1414medications like Naloxone to save lives.1415    VA supports the Protecting Veteran Access to Telemedicine1416Services Act also with amendments. VA greatly appreciates the1417Committee's engagement and attention on this issue, as well as1418the willingness to discuss technical issues VA has identified1419with the bill. VA recommends amendments to ensure this new1420authority effectively addresses the two significant barriers VA1421has experienced and ensuring providers can furnish care,1422including prescribing controlled substances to veterans through1423telehealth, restrictions with the CSA--Controlled Substances1424Act--and within the CSA, and variability in state law1425prescribing requirements. A clear federal framework would help1426us deliver consistent care to veterans wherever they live.1427    VA has concerns with the Written Informed Consent Act.1428While we support the goal of informed decision-making,1429requiring signature consent for a broad range of medications1430could lead to unintended consequences, such as a delay in1431access to care and increased stigma to mental health treatment1432that might deter veterans from accepting needed care. Our1433current policies already require completion of informed consent1434discussions and documentation in the electronic health record1435that is tailored to clinical risk.1436    In closing, VA is committed to ensuring safe, effective,1437and veteran-centered medication management that helps improve1438the lives of our Nation's heroes. We're proud of the progress1439we've made, but we know there's more to do. We'll continue to1440refine our practices, expand access to innovative treatments,1441and put veterans first in everything we do.1442    Thank you for your time and your continued support. We look1443forward to your questions.14441445    [The prepared statement of Dr. Wiechers appears on pages144671-84 of the Appendix.]14471448    Chairman Moran. Thank you. Let me turn to Senator1449Blumenthal. We need to ask questions in light of the scheduler1450vote----1451    Senator King. Mr. Chairman, I have to leave unfortunately1452for another meeting, but I want to compliment the department1453for the dramatic reduction of opioids prescribing. I think1454that's----1455    Senator Blumenthal. I'm happy to yield to you, Senator1456King, if you want to ask.1457    Senator King. No, that's all I wanted to comment. Thank you1458very much.1459    Senator Blumenthal. Thank you. Let me ask Dr. Wiechers, I1460noticed that you are on the faculty at Yale, so you're familiar1461with our VA facility in Connecticut. And as you know, Secretary1462Collins has repeatedly stated that access to VA care has not1463been affected by staffing reductions. But the VA's own data, in1464my view, tells a different story.1465    Wait times for new mental health appointments have1466increased sharply since January. In my home State, Connecticut,1467for example, the most recent data shows the current wait time1468for a new patient mental health appointment at the Orange VA1469Clinic in Connecticut, an outpatient facility specializing in1470mental health, is 208 days, nearly six months.1471    Let me ask you, given these kinds of wait times, how does1472the VA plan to prevent overreliance on medication when veterans1473can't access these timely appointments and what steps are1474necessary to address this issue?1475    Dr. Wiechers. Thank you for the question, Senator. I agree1476that access to timely mental health care is one of our top1477priorities. We continue to actively be recruiting and hiring1478mental health providers across the system. We are working to1479address the access challenges that you have noted. And it does1480vary from facility to facility.1481    So, acknowledge that there are differences based on1482location, but we're doing work now to identify areas of ways we1483can improve our efficiencies so that our workflow and our1484ability to see patients and get them access quickly----1485    Senator Blumenthal. You don't dispute the data showing1486those wait times?1487    Dr. Wiechers. I acknowledge that there are wait times at1488some facilities that are beyond what our expectation and1489standard----1490    Senator Blumenthal. I've also heard credible reports that1491some VA psychologists are being instructed to cap the number of1492sessions they can offer patients, even when in their1493professional judgments additional sessions are clinically1494necessary. I don't know how you justify that kind of practice.1495    Dr. Wiechers. There is no cap on the number of1496psychotherapy appointments that a veteran can have. There's no1497national policy. That wouldn't be----1498    Senator Blumenthal. So, you dispute that there are any caps1499that psychologists have been instructed to impose?1500    Dr. Wiechers. We support the implementation of evidence-1501based psychotherapies. Many of those evidence-based1502psychotherapies are a course of treatment that occurs sometimes15038 to 12 treatments, sometimes 12 to 20 treatments. The1504individual provider working with that veteran is the one who is1505determining that course of treatment and when it's appropriate1506to complete that work. But there is no cap set. There is no1507policy indicating a cap in the number of treatments available.1508It is a decision----1509    Senator Blumenthal. So, the answer to my question is yes,1510you dispute that any instructions have been provided that there1511should be a cap imposed by psychologists?1512    Dr. Wiechers. There's no national policy instructing to1513have a cap in----1514    Senator Blumenthal. Well, were psychologist ever told they1515have to impose caps?1516    Dr. Wiechers. I can't speak to what every individual1517psychotherapist across the country has been told by someone,1518but I can say that we don't have a policy that states that and1519that I wouldn't support it.1520    Senator Blumenthal. Well, I would just tell you, I'm going1521to cut through the verbiage in the interest of time. We've been1522told by multiple sources that caps have been imposed on1523psychologists. So, if you're not hearing it, I think the VA1524leadership needs to do a better job of listening to the1525psychologists and others who are actually providing care. In1526the interest of time, I'm going to yield.1527    Chairman Moran. Thank you, Senator Blumenthal. I'd suggest1528Dr. Wiechers, that you take Senator Blumenthal's commentary to1529heart and actually explore within the VA whether there's a1530policy or a written national policy, whether there's a practice1531that is limiting the ability for the treatment that the1532provider believes is necessary in some fashion. That makes1533sense to you?1534    Dr. Wiechers. That does make sense to me. And Senator1535Blumenthal, I'd like to continue the conversation with you and1536your staff further so I can make sure I understand what you're1537hearing better.1538    Senator Blumenthal. I would welcome that opportunity. And I1539just want to say this is not personal to you. I recognize you1540are not in charge of the VA healthcare system and both of you1541have long histories of service in the VA, which I appreciate. I1542thank you for your service and I know you have ultimately the1543goal of serving our veterans. And I want to be helpful to you1544in serving that goal.1545    Dr. Wiechers. Thank you, sir.1546    Chairman Moran. Dr. Emmendorfer, let me ask you maybe a1547question. I was able to attend the launch of the PHASER pilot1548program in 2019, I think it was. It was at the National Press1549Club, with Secretary Wilkie, and which introduced the idea of1550using a patient's DNA to prevent medication side effects and1551reduce the use of ineffective medications. I understand that1552program is successful. I'd like to have that confirmed and is1553now available in nearly every VA medical center.1554    How is the VA training providers to use this? How is the VA1555integrating the results into the VA's electronic health1556records? Tell me about this program and whether it matters.1557    Dr. Emmendorfer. Thank you, Senator, and I am happy to1558report that it is a success. As a matter of fact, earlier this1559week, we just learned that one more VA medical facility has1560implemented the pharmacogenomics program, and we expect the1561remaining seven VA medical facilities to implement1562pharmacogenomic testing by the end of the calendar year 2026.1563    For the training, we have over 1,000 VA providers that have1564participated in the continuing education program on1565pharmacogenomics. And then we also have our Academic Detailing1566Services program, which has especially trained pharmacists that1567have conducted outreach with, I believe, around 7,000 providers1568to help promote pharmacogenomics. It's well integrated into our1569electronic health record, so it's part of the clinical decision1570support system.1571    There's about 100 medications that are evidence-based with1572the pharmacogenomic testing. And so at the time of prescribing,1573the computer system, our electronic health record, will flag an1574alert on the pharmacogenomic testing, and that helps guide1575appropriate medication selection and therapy. So, we're very1576proud of the program.1577    Chairman Moran. Tell me, as the layman on so many things,1578what does the DNA tell us? What does it indicate? What is it1579capable of indicating to avoid in the treatment of a patient?1580    Dr. Emmendorfer. Yes, so it's helpful with the DNA because1581it will tell us as healthcare providers how we would expect1582that medication to behave when it's in your system and being1583metabolized by your body. And that information really helps us1584make that upfront selection of the medication. So, in the past1585where you may have to do some trials and then if the patient's1586trial on the medication wasn't optimal, and then you may have1587to taper and stop that medication and then try another1588medication. The pharmacogenomics takes that guesswork out1589upfront.1590    Chairman Moran. Thank you. Senator Blumenthal, anything you1591want to cover before I----1592    Senator Blumenthal. I would like to submit some additional1593questions for the record.1594    Chairman Moran. You also indicated you had something to1595submit for the record, I think.1596    Senator Blumenthal. I'm going to submit my statement and1597the letter that I wrote to Secretary Collins.1598    Chairman Moran. Without objection.1599    Chairman Moran. I'm sorry to cut this hearing short.1600Senator Blumenthal and I probably have access to more1601conversations with you, and I see you nodding your heads, and1602then we'll follow up with our staff to make sure that anything1603that we may have missed because of the vote is covered.1604    Chairman Moran. With no other questions, I want to once1605again, thank you for your testimony. I thank our Committee1606members for their participation and for our audience. Each1607member has five legislative days in which to submit statements1608or questions for the record.1609    Any Senator who would like to submit a question for the1610record to today's witnesses should do so in a timely manner.1611And likewise, I ask our witnesses to respond to any questions1612that they receive from this effort following today's hearing in1613a timely manner as well.1614    And with that, our Committee hearing is adjourned.1615    [Whereupon, at 5:18 p.m., the hearing was adjourned.]16161617                            A P P E N D I X16181619                           Opening Statement16201621[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]16221623                          Prepared Statements16241625[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]16261627                       Submission for the Record16281629[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]16301631                        Questions for the Record16321633[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]16341635                       Statements for the Record16361637[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]16381639                             [all]