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“Medication Management in VA Healthcare”

Senate Veterans Affairs Committee Hearing

December 3, 2025 (recording here)

HEARING INFORMATION

Witnesses & Written Testimony (linked) (Panel One):

• Alyssa Hundrup: Director, Health Care, U.S. Government Accountability Office

• Julie Kroviak, MD: Principal Deputy Assistant Inspector General, in the role of Acting Assistant Inspector General for Healthcare Inspections, Office of Inspector General, U.S. Department of Veterans Affairs

• Erin Fletcher, Psy.D.: Warrior Care Network Director, Wounded Warrior Project

Witnesses & Written Testimony (linked) (Panel Two):

• Ilse Wiechers, MD, MPP, MHS: Acting Deputy Assistant Under Secretary for Health for Patient Care Services, Veterans Health Administration, U.S. Department of Veterans Affairs

• Thomas Emmendorfer, Pharm.D.: Executive Director, Pharmacy Benefits Management (PBM) Services

Keywords mentioned:

• Veteran care, medication management, polypharmacy, mental health, opioid safety, community care, electronic health records, pharmacogenomics, naloxone access, informed consent, telemedicine, staffing, alternative therapies, overdose prevention, oversight

IN THEIR WORDS

OPENING STATEMENTS FROM THE COMMITTEE

• Chairman Jerry Moran opened by asserting that the nation owed veterans safe, high-quality, and effective care, including responsible medication management and access to supportive services. He mentioned recent reporting on the “combat cocktail” and raised concerns about the prevalence, origins, and oversight of complex central nervous system medication combinations prescribed to veterans. The Chairman highlighted the VA’s progress in reducing opioid prescriptions but stressed that gaps remained in training, monitoring, and offering non-medication treatment options. He stated that the purpose of the hearing was to understand the scope of these issues and identify steps the VA and Congress could take to ensure veterans receive safe, effective, and personalized care.

• Ranking Member Richard Blumenthal said that polypharmacy often reflected long wait times, insufficient clinical capacity, and fragmented care that pushed veterans toward multiple or conflicting medications. He expressed concern that recent reports indicated a departure from evidence-based, veteran-centered mental health care, and noted that he had written to VA Secretary Doug Collins regarding these issues. The Ranking Member also warned that staffing losses across the VA contributed to delays and reduced access to treatment alternatives. He then criticized the VA’s decision to impose co-payments for holistic services such as yoga and meditation, arguing that such fees discouraged veterans from seeking non-medication therapies.

SUMMARY OF KEY POINTS (PANEL ONE)

• Ms. Alyssa Hundrup testified that effective medication management was essential for ensuring veterans received safe and comprehensive treatment, particularly those experiencing mental health conditions or chronic pain. She summarized prior Government Accountability Office (GAO) findings showing gaps in VA documentation and monitoring of mental health treatment plans, which led GAO to issue recommendations the VA has since implemented. She also described GAO’s work on the VA’s opioid safety initiative, claiming that while prescribing rates had declined, the VA previously failed to consistently follow risk-mitigation strategies before implementing GAO’s recommendations. Ms. Hundrup advocated for stronger VA–Department of Defense (DOD) evaluation of mental health services for transitioning service members and affirmed that GAO would continue monitoring the VA’s progress.

• Dr. Julie Kroviak stated that medication reconciliation was a critical but labor-intensive process that helped prevent duplicative treatments, drug interactions, and other risks, especially during care transitions. She reported that Office of Inspector General (OIG) reviews had uncovered deficiencies in discharge instructions, patient education, and follow-up care, including a case where a young veteran died by suicide after receiving an antidepressant without adequate counseling or timely evaluation. She also raised concerns about insufficient oversight of community care providers, including weak adherence to the VA’s opioid safety guidelines and incomplete documentation of safe prescribing practices. Dr. Kroviak underlined that while VA clinicians worked tirelessly, improved oversight, patient education, and coordination were essential for preventing harm and ensuring safe medication management.

• Dr. Erin Fletcher reported that mental health needs remained significant among post-9/11 veterans, with high rates of PTSD, chronic pain, poor sleep, and isolation contributing to complex clinical challenges. She mentioned that polypharmacy was one symptom of broader access issues, including difficulty obtaining therapy, canceled appointments, and persistent stigma. Dr. Fletcher urged Congress and the VA to invest in precision medicine, expand access to non-pharmacological treatments such as yoga and acupuncture, and strengthen Whole Health implementation to reduce reliance on medication-first approaches. She also highlighted innovative case management models, such as the Warrior Care Network partnership, which had successfully improved continuity of care and veteran engagement with the VA.

• Chairman Moran asked all three witnesses how closely the problematic medication cases described in the Wall Street Journal aligned with what their offices or organizations had observed, and how their experiences differed.

  • Ms. Hundrup responded that prescribing decisions varied widely based on resources, provider comfort, treatment availability, and case complexity. She noted that GAO’s most recent data was from 2018 and showed significant levels of psychiatric prescribing and polypharmacy, but she emphasized that updated data from the VA was needed to understand current trends.

  • Dr. Kroviak replied that she found the article disappointing because, while the patient experiences were tragic and real, the reporting lacked the clinical context documented in medical records. She emphasized that OIG did not see evidence that VA clinicians were prescribing medication to avoid providing real care and reiterated that most VA providers were dedicated and compassionate.

  • Dr. Fletcher said that many warriors reported being offered medications before therapy was accessible, suggesting a need for better access to first-line psychotherapies and shared decision-making. When the Chairman asked if her comments differed from Dr. Kroviak’s, Dr. Fletcher confirmed that their observations were largely similar.

• Ranking Member Blumenthal asked to what extent mental health appointment wait times were driven by diminished staffing.

  • Dr. Fletcher shared that warriors consistently reported access-to-care difficulties and stressed that good outcomes depended on timely access to evidence-based treatment and strong patient involvement.

  • Dr. Kroviak also confirmed widespread shortages of mental health providers both inside and outside the VA, and added that morale in VA facilities had dropped due to federal uncertainty, leading to additional staff losses.

  • Ms. Hundrup agreed, noting national shortages and explaining that the VA lacked a timeliness standard for community care, preventing a full picture of how long veterans waited outside the VA system.

• The Ranking Member then asked Dr. Fletcher whether stronger safeguards and oversight were needed to prevent overmedication. Dr. Fletcher responded that warriors wanted more time with providers, a better understanding of their medications, and more consistent follow-up, all of which contributed to safer prescribing and reduced risks from inappropriate medication combinations.

• Sen. Tommy Tuberville asked whether the VA had a plan to enhance oversight and hold medical professionals accountable for overprescribing harmful medications. Dr. Kroviak said VA policies existed but were inconsistently implemented due to unclear oversight roles within VISNs. She argued that defined authority and accountability were essential for enforcing safe prescribing. Ms. Hundrup echoed that improved documentation and clear treatment plans would enable better monitoring of outlier prescribing and help the VA take corrective action.

• Sen. Tuberville inquired whether oversight was needed for foreign-manufactured drugs used by the VA. Dr. Fletcher replied that Wounded Warrior Project (WWP) focused on ensuring veterans were informed and that treatment recommendations were evidence-based and safe. Dr. Kroviak said medication safety oversight would occur outside the VA but agreed that increased scrutiny of medication sourcing was reasonable. Ms. Hundrup added that she lacked specific expertise but agreed that it was an important issue requiring VA attention.

• Sen. Tuberville asked whether expanding access to therapies like hyperbaric oxygen therapy (HBOT) and psychedelic-assisted treatment could help reduce polypharmacy. Dr. Fletcher agreed that many warriors were interested in alternative treatments, especially when traditional therapies had not worked, but underscored that any new approach must prioritize patient safety and evidence-based practice.

• Sen. Mazie Hirono asked whether each veteran with PTSD was supposed to have an individualized treatment plan, and who was responsible for creating it. Dr. Kroviak replied that veterans diagnosed and treated for PTSD were required to have treatment plans created and monitored by their healthcare team. Dr. Fletcher said experiences varied and that not all veterans consistently received individualized plans, though evidence-based treatment often enabled personalization when available.

• Sen. Hirono then asked whether ongoing provider shortages, already long-standing, had been exacerbated under recent staffing cuts. Dr. Kroviak confirmed that OIG’s annual critical staffing report showed the most significant increases in shortages in years.

• Sen. Hirono challenged how GAO’s recommendations for greater oversight could be met when VA staffing was simultaneously being cut. Ms. Hundrup responded that oversight effectiveness depended on proper implementation of policies, but Sen. Hirono observed that cuts made oversight more difficult.

• Sen. Hirono asked Dr. Fletcher whether expanding access to alternative forms of care was a fruitful path forward, given provider shortages. Dr. Fletcher reiterated that alternative therapies had value, especially when veterans did not benefit from traditional treatments, and that innovation in mental health care remained essential.

• Sen. Tim Sheehy discussed the importance of community care in rural states like Montana, then asked Ms. Hundrup how Congress could ensure that a proposed written informed consent requirement would be properly implemented if passed. Ms. Hundrup said informed consent was critical because it ensured patients understood medication risks. She explained that GAO previously found gaps in the VA’s opioid informed consent process and recommended improvements that led to a tool and medical record flag indicating whether consent had been obtained. She suggested that expanding such medical-record–based flags to other medications could help ensure proper execution of a new informed consent requirement.

• Sen. Sheehy asked whether the VA was currently structured to implement such a policy effectively. Ms. Hundrup responded that GAO had not assessed this recently, but her understanding was that the opioid consent tool remained active in medical records. She acknowledged the VA’s ongoing electronic health record (EHR) transition but believed adding similar functionality should be feasible if the prior system was still in place.

• Sen. Sheehy then asked whether this issue underscored the need for a seamless DOD–VA electronic health record to prevent gaps in documentation and care for service members transitioning out of the military. Ms. Hundrup agreed completely and stated that a unified record was essential to avoid losing critical medical information between the two systems.

• Sen. Sheehy highlighted alternative treatment options such as psychedelics and non-traditional therapies and noted he would host a roundtable addressing these issues. He asked Dr. Fletcher to reaffirm the importance of alternative treatments in the broader veteran care ecosystem. Dr. Fletcher restated that many veterans sought alternative therapies, especially when traditional treatments failed, and said the VA should remain open to innovation while ensuring patient safety.

• Sen. Angus King claimed that many problems stemmed from failures in electronic medical records. He asked whether AI could help identify dangerous drug interactions more effectively. Ms. Hundrup agreed that AI could have promise in this area, though GAO had not evaluated it in depth. She said the VA had indicated interest in using AI to implement GAO recommendations, but the technology was still early-stage.

• Sen. King asked whether the VA performed routine annual medication reviews. Dr. Kroviak explained that medication reconciliation occurred at every patient encounter and that existing EHR systems already checked new prescriptions against a patient’s medication list and allergy history. She noted that providers must interpret alert severity and decide whether risks are acceptable.

• Sen. King asked whether gaps in coordination with community care remained a major problem. Dr. Kroviak confirmed this was a significant issue and that interoperable EHR systems remained a long-term solution still far from reality.

• Sen. Maggie Hassan asked why it was so important for the DOD and VA to assess the effectiveness of their mental health support efforts for transitioning service members. Ms. Hundrup said many programs offered valuable engagement points but were often late, duplicative, or confusing, leading to missed opportunities for timely support. She stressed that a thorough assessment across programs would identify gaps, timing issues, and redundancies, ultimately improving mental health access during the vulnerable transition period.

• Sen. Hassan questioned what problems continued to prevent proper oversight of opioid prescriptions in community care and what Congress could do to help. Dr. Kroviak replied that two OIG recommendations remained unimplemented, both tied to information sharing and oversight failures with third-party administrators. She mentioned that addressing these issues would likely require contract modifications and reported that VA leadership was taking OIG concerns seriously during upcoming contract renewals.

• Chairman Moran pledged to follow up on community care oversight concerns, including whether veterans were facing actual clinical risks or whether gaps were primarily documentation-related. He also asked Dr. Fletcher whether perceptions of “prescription first” care were grounded in fact and sought clarity on whether VA had truly reduced opioid overprescribing. He reserved these topics for staff follow-up discussions.

• Ranking Member Blumenthal asked Ms. Hundrup whether the Wall Street Journal’s finding that only 15% of veterans with depression, PTSD, or anxiety were offered psychotherapy instead of medication was still accurate. Ms. Hundrup said she did not have updated data but had no specific reason to believe the number had changed, underscoring the need for updated public reporting.

SUMMARY OF KEY POINTS (PANEL TWO)

• Dr. Ilse Wiechers stated that the VA managed complex medication needs for veterans with conditions such as PTSD, chronic pain, and substance use disorders. She affirmed the agency’s commitment to reducing unnecessary or unsafe prescribing, pointing to several examples of major progress on opioid safety. She also described ongoing initiatives such as the Psychotropic Drug Safety Initiative and a new effort to identify innovative software tools for individualized medication review and deprescribing. Finally, she summarized the VA’s views on pending legislation, expressing support (with amendments) for the overdose prevention and telemedicine bills, and raising concerns that the proposed written informed consent act could delay care and increase stigma around mental health treatment.

• Ranking Member Blumenthal asked how the VA planned to prevent overreliance on medication when wait times for new mental health appointments, such as the 208-day wait at the Orange, Connecticut clinic, had increased sharply. Dr. Wiechers said timely mental health access was a top priority and that the VA was actively recruiting and hiring providers while examining workflow efficiencies. She acknowledged that wait times varied by facility and that some were higher than expected.

• The Ranking Member then stated he had received credible reports that psychologists were being instructed to cap the number of therapy sessions, and he asked whether such caps existed. Dr. Wiechers stated that no national VA policy imposed caps on psychotherapy sessions and emphasized that evidence-based treatments often had typical course lengths. When pressed, she reiterated that she could not speak to every local instruction but maintained that the VA had no policy dictating session limits. Ranking Member Blumenthal asserted that multiple sources reported caps, and Chairman Moran asked Dr. Weikers to follow up internally to determine whether such practices were occurring despite the absence of a national policy.

• The Chairman asked whether the VA’s pharmacogenomics program had been successful, and he asked how the VA trained providers and integrated test results into electronic health records. Dr. Thomas Emmendorfer confirmed the program was a success and reported that nearly all VA medical centers had implemented pharmacogenomic testing, with the final sites expected by the end of 2026. He stated that over 1,000 providers had completed pharmacogenomics continuing-education training and that academic detailing pharmacists had conducted outreach to about 7,000 clinicians. He added that test results were embedded in the electronic health record’s clinical decision support system, allowing alerts for roughly 100 evidence-supported medications.

• Chairman Moran asked, as a layperson, what DNA testing actually revealed about medication response. Dr. Emmendorfer said pharmacogenomic data indicated how a patient’s body was likely to metabolize a medication, enabling more accurate upfront prescribing and reducing the need for trial-and-error medication adjustments.

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