    [Senate Hearing 110-377]
    [From the U.S. Government Publishing Office]

                                                            S. HRG. 110-377

                      OVERSIGHT HEARING: HIRING PRACTICES AND
                      QUALITY CONTROL IN VA MEDICAL FACILITIES
    =======================================================================

                                     HEARING
                                    BEFORE THE
                          COMMITTEE ON VETERANS' AFFAIRS
                               UNITED STATES SENATE
                               ONE HUNDRED TENTH CONGRESS
                                    FIRST SESSION
                                    -------------
                                   NOVEMBER 6, 2007
                                    -------------
               Printed for the use of the Committee on Veterans' Affairs

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                          COMMITTEE ON VETERANS' AFFAIRS

                         DANIEL K. AKAKA, Hawaii, Chairman
    JOHN D. ROCKEFELLER IV, West Virginia RICHARD M. BURR, North Carolina,
    PATTY MURRAY, Washington                Ranking Member
    BARACK OBAMA, Illinois                ARLEN SPECTER, Pennsylvania
    BERNARD SANDERS, (I) Vermont          LARRY E. CRAIG, Idaho,
    SHERROD BROWN, Ohio                   JOHNNY ISAKSON, Georgia
    JIM WEBB, Virginia                    LINDSEY O. GRAHAM, South Carolina
    JON TESTER, Montana                   KAY BAILEY HUTCHISON, Texas
                                          JOHN ENSIGN, Nevada
                        WILLIAM E. BREW, Staff Director
                      LUPE WISSEL, Republican Staff Director

                                   C O N T E N T S

                                   --------------

                                   NOVEMBER 6, 2007

                                      SENATORS

                                                                       Page
    Akaka, Hon. Daniel K., Chairman, U.S. Senator from Hawaii ........... 1
    Burr, Hon. Richard M., Ranking Member, U.S. Senator from
      North Carolina .................................................... 2
    Durbin, Hon. Richard J., U.S. Senator from Illinois ................. 3
    Murray, Hon. Patty, U.S. Senator from Washington .................... 5

                                      WITNESSES

    Cross, Gerald M., M.D., Principal Deputy Under Secretary for Health, U.S.
    Department of Veterans Affairs; accompanied by Peter Almenoff, M.D.,
    Director, Veterans Integrated Service Network 15; Dr. George O. Maish,
    Jr., Chief of Surgery, Lenanon, Pennsylvania, VA Medical Center; and
    Kathryn Enchelmayer, Director of Quality Standards, Veterans Health Administration ...................................................... 6
      Prepared statement ................................................ 8
    Williamson, Randall B., Acting Director, Health Care, U.S. Government Accountability Office .............................................. 21
      Prepared statement ............................................... 22
    Duckworth, Tammy, Director, Illinois Department of Veterans'
      Affairs .......................................................... 38
    Prepared statement ................................................. 39
    McCarthy, Steven, Veteran, Operation Iraqi Freedom ................. 42
    Prepared statement ................................................. 44

                                      APPENDIX

    American Academy of Physician Assistants; prepared statement ....... 51

                              OVERSIGHT HEARING: HIRING PRACTICES
                                 AND QUALITY CONTROL IN VA MEDICAL
                                 FACILITIES

                                           ------------

                                   TUESDAY, NOVEMBER 6, 2007

                                                   U.S. SENATE,
                                    COMMITTEE ON VETERANS' AFFAIRS,
                                                           Washington, D.C.

      The Committee met, pursuant to notice, at 9:34 a.m., in room SD-562,
    Dirksen Senate Office Building, Hon. Daniel K. Akaka, Chairman of the
    Committee, presiding.

    Present: Senators Akaka, Murray, Durbin and Burr

                 OPENING STATEMENT OF HON. DANIEL K. AKAKA, CHAIRMAN,
                               U.S. SENATOR FROM HAWAII

      Senator AKAKA. This hearing will come to order. This morning's
    hearing will focus on hiring practices and quality controls in VA
    hospitals and clinics. Among the issues we will address are the recent
    events at the Marion, Illinois, VA Medical Center. VA's internal
    tracking found a sharp and disturbing increase in the number of deaths
    at that hospital. In addition, they found cases of serious and
    unexpected complications from routine surgeries performed there.

        As Chairman of the Senate Committee on Veterans' Affairs, it is
    very important to me that all veterans get the best possible care from
    the best possible health care practitioners. To achieve that goal, we
    must ensure that all providers are appropriately checked for their
    credentials and privileges.
        I note that the Inspector General�s office is in the midst of an
    investigation about the personnel involved in those events at the
    Marion VA, and because of this the IG will not be testifying today.
        Knowing of Senator Durbin's interest, and with Senator Burr's
    concurrence, I have asked Senator Durbin to join us on the dais for
    this hearing. While this issue was brought to my attention due to the
    troubling situation at the Marion VA, it may indeed have implications
    for the entire VA health care system and the more than 140,000
    providers employed by VA.
        When the IG's investigation is complete, the Committee will review
    that report to ensure that no structural problems exist in VA's
    process to appropriately screen its employees. If systemic problems
    are found, we will work to address them.
        I want to thank you all for being here, and we look forward to the
    testimony of our witnesses.
        At this time I would like to call on our Ranking Member for his
    comments, and then we will turn to Senator Durbin.

              STATEMENT OF HON. RICHARD M. BURR, RANKING MEMBER,
                      U.S. SENATOR FROM NORTH CAROLINA

        Senator BURR. Thank you, Mr. Chairman. I appreciate you calling
    this hearing to look into what I think are extremely important matters.
    I would like the record to note that I know that there is interest on
    the part of Senator Durbin and Senator Obama, and were this North
    Carolina, I would have the same interest, and I am sure Senator Murray
    would for Washington. And as Committee Members, it is our
    responsibility to look into this. I asked the Chairman, though, not to
    hold this hearing because I think it is premature and inappropriate
    when there is a current investigation going on to believe that we can
    get to the bottom of the problem and that, in fact, we might--and I
    stress the word ``might''--encumber the IG's investigation by what might
    be said, what might be reported, or what might be asked.
        So, I reluctantly am here today. I understand the need of the
    State's Senators to be in front of this issue, and I respect the fact
    that both of them have been very vocal on it. And it is my
    understanding that the VA is currently in the process of sending a team
    in to look at multidisciplinary assessments of the entire Marion
    facility.
        We do owe our veterans not only the very best medical care but also
    the highest quality professionals that we can put there to deliver that
    care. One way to show our commitment to our veterans is to ensure that
    the VA's hiring practices conform to the highest standards possible.
    However, these recent allegations of substandard care at the Marion VA
    Medical Center have called into question the VA's current system for
    credentialing and privileging health care professionals.
        Everyone in the veterans community--including those who care for
    veterans professionally, concerned family members, and veterans
    themselves--was alarmed when they learned of the sharp rise in deaths
    at Marion. These deaths have raised many questions about whether
    substandard care and poor hiring practices are to blame.
        As you pointed out, Mr. Chairman, the VA Inspector General is in
    the midst of an investigation into the deaths at the Marion VA
    facility, which is why he declined to testify at today's hearing, and I
    am glad he did decline. I have spoken to the Inspector General. He has
    assured me this is an active, ongoing investigation, and that when that
    investigation is complete, he intends to fully brief this Committee and
    to make himself available for any requests for hearings.
        Mr. Chairman, I would suggest today, rather than jump to
    conclusions about what did or did not happen, or what may or may not be
    wrong with VA credentialing, that we wait until the IG has done his
    work. Let him investigate these issues and report back his findings. At
    that time, we will be better able to answer questions such as: Was the
    VA credentialing or privileging process itself at fault? Was the Marion
    facility negligent in following the established VA process? And what
    exactly happened at Marion and, more importantly, who is responsible?
        Mr. Chairman, we owe it to the surviving families to get to the
    bottom of the Marion case. We also owe it to our veterans to find out
    whether the rise in deaths at Marion is a warning sign of a system-wide
    credentialing and privileging problem within the VA.
        Mr. Chairman, I know we both share a desire to see that these
    issues are thoroughly investigated. Once the IG's work is complete, I
    hope you will be calling a hearing, one where we can call the
    appropriate witnesses--not that those who are here today are not
    welcomed, but that we can look at the facts and ask the hard questions
    but, more importantly, get the right answers as it relates to the
    Marion VA facility.
        So, Mr. Chairman, again, I thank you for the opportunity to be
    here. I welcome my colleagues, Senator Durbin and Senator Murray, and I
    am sure that if, in fact, there is some information to glean today, we
    will glean that.
        Senator AKAKA. Thank you, Senator Burr.
        Senator Durbin?

                     STATEMENT OF HON. RICHARD J. DURBIN,
                          U.S. SENATOR FROM ILLINOIS

        Senator DURBIN. Mr. Chairman, thank you very much, and, Senator
    Burr, thank you for agreeing to this hearing. And I would like to say
    at the outset that Senator Obama and I have been involved in this from
    the start. Although he is not here this morning, he certainly shares my
    concern about what has happened at the Marion VA Hospital.
        Let me say at the outset that the Marion VA Medical Center has
    served veterans in our region for generations, with extraordinarily
    good professional care. It enjoys a great reputation in southern
    Illinois, Indiana, and Kentucky for providing that care for veterans
    who have served us so honorably in many places around the world. And
    that is why this current situation is so troubling.
        Let me concur with Senator Burr. We will not know the details on
    what happened here until the inspection is complete. There are, in
    fact, two inspections underway--one by the Inspector General's office
    and the other, I am told, by the quality assurance team at the Veterans
    Administration. And I welcome their conclusions, and I hope they are
    presented thoroughly and very soon.
        But there are some things that we do know that are indisputable,
    and the information I am about to relate has been related directly to
    me by the Veterans Administration and I think is the reason why we can
    meet today and talk about some of the larger issues that this presents.
        We know that in August of this year, it came to the attention of
    the Veterans Administration that there was a dramatic increase in
    surgical deaths at the Marion VA Medical Center, so much so that
    investigative teams were sent quickly and determined to give
    administrative leave to four of the top administrators at this Marion
    hospital. Shortly thereafter, a surgeon resigned--Dr. Mendez--and
    surgical activities were severely curtailed at the Marion hospital.
    That continues to this day while the investigation is underway.
        There have been serious questions raised about the credentialing of
    the doctor who resigned, and I think that is what has given rise to our
    need for this hearing. This doctor was licensed in the State of
    Massachusetts and in the State of Illinois when he came on the staff of
    the Marion VA Medical Center. And it was after that time, about a year
    after, maybe a year and a half after he came on at the Marion VA
    Medical Center, that he surrendered his license in the State of
    Massachusetts to practice medicine, and it was characterized as for
    ``nondisciplinary reasons.'' When he was asked why he would surrender
    his license to practice, he indicated he did not plan on returning to
    Massachusetts and he did not want to continue to pay the fees that were
    involved. I think those facts are basic and not much dispute about
    them.
        We have come to learn that before he was hired by the Marion VA
    Hospital, he had two malpractice cases filed against him in the State
    of Massachusetts and one disciplinary action by a hospital. The
    question that I think this raises is: What is due diligence? What
    should the VA use as their standard to determine whether a doctor is
    fit and competent to practice at a Marion VA medical facility or any VA
    medical facility?
        There are serious questions that have been raised here about the
    level of communication, for example, between the State of Massachusetts
    and the VA medical system in general and Marion VA in particular. As I
    understand it, a person can practice at a VA facility without being
    licensed in the State where that VA facility exists. And so, obviously,
    there is a need for communication with other States and other licensure
    boards to find out whether anything extraordinary has happened.
        Since this investigation is underway, it has been publicly reported
    that another doctor has been suspended at the Marion VA Medical Center
    for his failure to disclose that he was licensed in another State. The
    reason that is important, of course, is that we want to keep on top of
    that situation to see if there have been any problems with that
    licensure in the other State.
        Well, under the circumstances here, there are a lot of questions
    that need to be asked and answered about the policies of
    credentialing medical professionals who come into the VA medical
    system. I have been told that there are some 15,000 to 18,000 doctors
    in the system at this time. So, clearly, this is a major responsibility
    and undertaking by the VA.
        The one point I would like to make to Senator Burr--and I hope he
    will understand and appreciate�is that I asked Members of my staff to
    go down to Marion and to talk to some of the people who were there.
    They have established a line of communication with a number of people
    who are participating in the investigation, as they should, and I
    encourage them to. But the sad reality is that at least three or four
    people with significant information in important positions at the
    Marion VA Medical Center have communicated to my office that they are
    unwilling to come forward, and they do not want to give this
    information for fear of reprisal and for fear of being terminated.
        Now, let me say in conclusion here a word about Acting VA Secretary
    Gordon Mansfield. I did not know the man until we got involved in this
    issue. He has come by my office, and we have spoken on the phone
    several times. I do not think we could ask for a better person to be
    head of the Veterans Administration. Mr. Mansfield is a veteran of
    Vietnam. He still carries the wounds from those battles. And I am
    convinced, I am personally convinced, that he is dedicated to the
    veterans in our country above everything else. His responses to me
    throughout have been clear and unequivocal. He wants to know what
    happened here. He wants to get to the truth, and he wants to protect
    those who will come forward in an honest fashion to tell what happened.
    He has said that to me repeatedly and said it again this morning. He
    told me that he is sending a special team now from the Veterans
    Administration to Marion to try to establish a better line of
    communication here.
        We really need to get all the information and facts in, and, Senator
    Burr, I hope that this hearing, which will be reported, I am
    sure, back in Illinois, will be an indication to those employees to
    cooperate in good faith with the investigation, to feel that they can
    come forward and tell what happened honestly in this circumstance and
    get to the truth of it.
        In the meantime, I hope this hearing will help us understand the
    process that is being followed to make certain that this never happens
    again and that we do everything we can to make sure that people in the
    VA medical system, the medical professionals, are skilled and
    competent.
        Thank you.
        Senator AKAKA. Thank you.
        Senator Murray?

                       STATEMENT OF HON. PATTY MURRAY,
                         U.S. SENATOR FROM WASHINGTON

        Senator MURRAY. Thank you very much, Mr. Chairman and Senator Burr,
    for holding today's important hearing on the tragic events that
    happened in Marion. Even with all of the controversy that is going on
    with the Department of Veterans Affairs within the context of this
    conflict, I know and I believe that overall our physicians and our
    clinical staff at the VA provide excellent care for our veterans. We
    hear it everywhere we go. The VA health care system has been an
    innovator in clinical care, in research in areas like PTSD and trauma
    care and electronic medical records, and they boast some of the most
    talented, knowledgeable physicians and staff in the country. So it was
    for that reason that I was deeply concerned when I heard about the
    physician at the Marion VA that was responsible apparently for
    providing care to our veterans that may have put them in danger.

        So I hope that today�s hearing, Mr. Chairman, is an opportunity to
    look at the procedures that are in place in the VA in terms of
    screening physicians and clinical staff so that we know the best
    procedures are in place so that an incident like this will not occur.
     And I think it is important that we ask the question of whether or not
    this was an isolated event or whether we have a system-wide issue. We
    want to know how common these problems are or possibly could be within
    the system. And I would like to know what the process is that the VA
    does have for screening health care providers as we are in the process
    right now of hiring a number of new physicians as we are putting a lot
    more resources, importantly, as we should be�into the VA today and,
    importantly, how we can prevent a tragedy like this from ever occurring
    again.
        So I think today's hearing is extremely important. I think the men
    and women in uniform who serve us very proudly have a right to know
    that we are doing due diligence to make sure that the care that they
    get is the best possible, that we have safe and effective care for
    them. That is the highest quality care available. So I appreciate the
    opportunity to have this hearing today, and I look forward to hearing
    from all of our witnesses so that we can learn from the tragedy that
    has occurred.
        Thank you.
        Senator AKAKA. Thank you. Thank you very much, Senator Murray.
        I want to welcome the first panel, from the Department of Veterans
    Affairs, Dr. Gerald M. Cross, Principal Deputy Under Secretary for
    Health. He is accompanied by Dr. Peter Almenoff, Director of the VA
    Heartland Network; and Dr. George O. Maish, Jr., Chief of Surgery at
    the Lebanon, Pennsylvania, VA Medical Center; and Kate Enchelmayer,
    Director of Quality Standards for the Veterans Health Administration. I
    want to thank you all for being here today, and as I mentioned in my
    opening statement, we are focusing on hiring practice as well as
    quality controls in VA hospitals and clinics. And, of course, what has
    happened in the Marion event also plays in this, and we are looking at
    credentials of the medical professionals.
        And, with that, Dr. Cross, will you please begin?

                STATEMENT OF GERALD M. CROSS, M.D., PRINCIPAL DEPUTY
                  UNDER SECRETARY FOR HEALTH, U.S. DEPARTMENT OF
                  VETERANS AFFAIRS; ACCOMPANIED BY PETER ALMENOFF,
                  M.D., DIRECTOR, VETERANS INTEGRATED SERVICE NETWORK
                  15; GEORGE O. MAISH, JR., M.D., CHIEF OF SURGERY,
                  LEBANON, PENNSYLVANIA, VA MEDICAL CENTER; AND
                  KATHRYN ENCHELMAYER, DIRECTOR, QUALITY STANDARDS,
                  VETERANS HEALTH ADMINISTRATION

        Dr. CROSS. Good morning, Mr. Chairman and Members of the Committee.
    Thank you for the opportunity to come here today to discuss VA's
    Credentialing and Privileging and its impact on current events at the
    Marion VA health care facility. I am accompanied by Ms. Kate
    Enchelmayer, our Director of Quality Standards, to my right; Dr. Peter
    Almenoff, at the end of the desk, the Director of Veterans Integrated
    Service Network 15; and Dr. George Maish, Jr., Chief of Surgery,
    Lebanon, Pennsylvania, VA Medical Center.

        My testimony will summarize our extensive credentialing and
    privileging process. I will also describe the National Surgery Quality
    Improvement Program, now famously known as NSQIP, that prompted our
    investigation at Marion.

        Before I begin, please be assured that my foremost priority, VA's
    foremost priority, is the care and well-being of our patients, our
    veterans. That priority is what led us to take swift action at the
    Marion VA facility.Credentialing: Credentials are a person's
    educational, training, experience, current competence, health status,
    certification, and licensure documents. VA's standardized electronic
    credentialing program, called ``VetPro,'' is used system-wide to
    document the credentials of health care providers. VA realizes that
    accurate credentialing is a cornerstone to ensuring qualified health
    care providers are hired and, in addition to the credentialing done
    on every licensed provider, the process of privileging that provider
    to administer care within the scope of his license and clinical
    competence and within the medical center's supporting capability
    remains an essential part of the initial processing that must be
    completed before the provider begins his duties within the VA. This
    process is completed on initial appointment and at a minimum of
    every 2 years thereafter, before transfer from another medical
    facility, or whenever the provider requests an addition to his or her
    privileges.
        The credentialing officer at a medical center obtains primary
    source information on all credentials. This is accomplished by direct
    contact with the source providing the education, training,
    certification, licensure, or registration. Information submitted by an
    individual health care practitioner is verified at that source. This
    includes confirming the practitioner's answers to
    17supplemental--sometimes called ``attestation''--questions specific to
    denial, surrender, revocation, and termination of a credential,
    privileges, and medical society affiliation, as well as any
    convictions. If a provider's license required for the position within
    VHA has ever been revoked or surrendered for cause�that is, for reasons
    of substandard care, professional misconduct, or professional incompetence�that provider is not eligible for employment in VHA unless
    that license has been fully restored. All practitioners must possess at
    least one full, active, current, and unrestricted license to practice.
        In addition, VA uses other flagging systems during the
    credentialing process and the determination of suitability for
    employment. These include, but are not limited to, the National
    Practitioner Data Bank-Health Integrity and Protection Data Bank, and
    the Disciplinary Alerts Service of the Federation of State Medical
    Boards. Moreover, VA continuously monitors physician licensure for any
    disciplinary or untoward activity with the FSMB. VA also queries a
    database maintained by the Office of the Inspector General at the
    Department of Health and Human Services that lists all individuals and
    entities that are currently excluded from participation in Medicare,
    Medicaid, and all other Federal health care programs.
        VA also uses the background investigation that is generally
    required on all new Federal employees. It consists of a National Agency
    Check, the Defense Clearance and Investigations Index, the FBI
    Identification Division�s name and fingerprint files; as well as
    written inquiries and searches of records covering specific areas of a
    person's background during the past 5 years. Those inquiries are sent
    to current and past employers, schools attended, references, and local
    law enforcement authorities.
        Now to clinical privileging. In VA, health care providers licensed
    for independent practice are given ``privileges'' that cover the
    breadth of their area of clinical practice. Specifically, these
    privileges are permissions to perform the individual procedure(s).
    These requested procedures are recommended by the executive committee
    of the medical staff and approved by the medical center director in
    accordance with medical center bylaws. Clinical privileges are focused
    on provider clinical practice and are medical center-specific,
    provider-specific, and within the scope of the provider's licensure,
    training, experience and competency, medical/clinical knowledge,
    and the provider's health. Consideration is also given to any
    information related to medical malpractice allegations or judgments,
    loss of medical staff membership, and loss of clinical privileges.
        Clinical privileges are granted for a period not to exceed 2 years
    at which time they must be re-evaluated and reissued. The service chief
    assesses updated information that mirrors items reviewed at the
    provider's initial appointment. The service chief then recommends which
    privileges should be granted or re-granted to the executive committee
    of the medical staff which is chaired by the medical center chief of
    staff. The executive committee evaluates the materials to determine if
    medical and clinical knowledge and clinical competence are adequately
    demonstrated to support recredentialing and the granting of the
    requested privileges. A final recommendation is then submitted to the
    medical center director who is the authority to grant privileges.
        Now I want to mention NSQIP. NSQIP is that program that gathers
    aggregate data from surgical outcomes to determine whether there are
    significant deviations in mortality or morbidity rates for major
    surgical procedures. Since the beginning of fiscal year 2007, this
    information is reported on a quarterly basis. Prior to that time, the
    information had been gathered yearly. It was decided that NSQIP would
    be a better tool if the data were gathered more frequently. This was
    reinforced when our NSQIP data was evaluated after the onset of the new
    timing.
        In response to an elevated ratio of expected surgical deaths during
    the first two quarters of fiscal year 2007, we, the VA, sent a NSQIP
    team to conduct an onsite visit at the Marion, Illinois, VA Medical
    Center. This was conducted as part--
        Senator AKAKA. Dr. Cross, will you please summarize your statement?
        Dr. CROSS. In conclusion, Mr. Chairman, VA has multiple tools in
    place for assessing and evaluating health care, and they are working,
    as in this case, to identify any irregularities and to correct them.
    These tools are part of the ongoing processes that are used to not only
    reveal the positive but also the vulnerabilities and deficiencies. We
    acknowledge these findings and seek to actively address the challenges
    they present. Moreover, the lessons learned are disseminated to health
    care providers throughout our health care system.
        Thank you, sir.
        [The prepared statement of Dr. Cross follows:]

              PREPARED STATEMENT OF DR. GERALD CROSS, PRINCIPAL DEPUTY UNDER
                   SECRETARY FOR HEALTH, DEPARTMENT OF VETERANS AFFAIRS

        Good morning, Mr. Chairman and Members of the Committee. Thank you
    for the opportunity to come here today to discuss VA's Credentialing
    and Privileging and its impact on current events at the Marion VA
    health care facility. I am accompanied by Ms. Kate Enchelmayer, our
    Director of Quality Standards, Dr. Peter Almenoff, Director of Veterans
    Integrated Service Network 15, and Dr. George Maish, Chief of Surgery,
    Lebanon, Pennsylvania, VA Medical Center.

                                CREDENTIALING

        Credentials are a person's educational, training, experience,
    current competence, health status, certification and licensure
    documents. The Department of Veterans Affairs' (VA) standardized
    electronic credentialing program, VetPro, is used system-wide to
    document the credentials of health care providers. VA realizes that
    accurate credentialing is a cornerstone to ensuring qualified health
    care providers come into the system. In addition to the credentialing
    done on every licensed provider, the process of privileging that
    provider to administer care within the scope of his license and
    clinical competence and within the medical center's supporting
    capability remains an essential part of the initial processing that
    must be completed before the provider begins his duties within the
    Veterans Health Administration (VHA). This process is completed on
    initial appointment and at a minimum of every 2 years thereafter,
    before transfer from another medical facility, or whenever the provider
    requests an addition to his privileges.
        The Credentialing Officer at a medical center obtains primary
    source information on all credentials. This is accomplished by direct
    contact with the entity providing the education, training,
    certification, licensure or registration. Information submitted by an
    individual health care practitioner is verified with that entity. This
    includes confirming the practitioner's answers to 17
    supplemental/attestation questions specific to denial, surrender,
    revocation and termination of a credential, privileges, and medical
    society affiliation, as well as felony charges and any convictions. If
    a provider's license required for the position within VHA has ever been
    revoked or surrendered for cause (i.e., for reasons of substandard
    care, professional misconduct, or professional incompetence), that
    provider is not eligible for employment in VHA unless that license has
    been fully restored. The practitioner also is required to possess at
    least one full, active, current, and unrestricted license to practice.
        In addition, VA uses other flagging systems during the
    credentialing process and the determination of suitability for
    employment. These include the National Practitioner Data Bank--Health
    Integrity and Protection Bank (NPDB-HIPDB), the Disciplinary Alerts
    Service of the Federation of State Medical Board (FSMB), the Health and
    Human Services Office of Inspector General List of Excluded Individuals
    and Entities (LEIE), the National Agency Check and Inquiry (NACI), and
    the Special Agreement Check (SAC) (fingerprint check). The NPDB is
    queried for reports of malpractice payments or adverse actions against
    clinical privileges by another entity.
        The HIPDB, which is a national data collection program for the
    reporting and disclosure of certain final adverse actions taken against
    health care practitioners, providers, and suppliers, is queried.
    Moreover, VA continuously monitors physician licensure for any
    disciplinary or untoward activity with the FSMB. VA also queries the
    LEIE, which is a database maintained by the Office of the Inspector
    General at the Department of Health and Human Services that lists all
    individuals and entities that are currently excluded from participation
    in Medicare, Medicaid and all other Federal health care programs.
        The NACI is the basic and minimum background investigation
    generally required on all new Federal employees. It consists of a
    National Agency Check (NAC) of OPM's Security/Suitability
    Investigations Index (SII); the Defense Clearance and Investigations
    Index (DCII); the FBI Identification Division�s name and fingerprint
    files; as well as written inquiries and searches of records covering
    specific areas of a person's background during the past 5 years. Those
    inquiries are sent to current and past employers, schools attended,
    references, and local law enforcement authorities.
        Providers as well as all applicants are subject to a pre-employment
    background investigation. The SAC, an OPM investigation tool is a
    fingerprint based criminal history check that is processed through the
    FBI.

                         CLINICAL PRIVILEGING (PRIVILEGES)

      In VA, a health care provider licensed for independent practice is
    given ``privileges'' that cover the breadth of their area of clinical
    practice. Specifically, these privileges are permissions to perform the
    individual procedure(s). These requested procedures are recommended by
    the executive committee of the medical staff and approved by the
    medical center director in accordance with medical center bylaws.
    Clinical privileges are focused on provider clinical practice and are
    medical center-specific, provider-specific, and within the scope of the
    provider's licensure, training, experience and competency,
    medical/clinical knowledge and provider health status (as it relates to
    the individual's ability to perform the requested clinical privileges).
    Consideration is also given to any information related to medical
    malpractice allegations or judgments, loss of medical staff membership,
    and loss or reduction in clinical privileges.
        Clinical privileges are granted for a period not to exceed 2 years
    at which time they must be re-evaluated and reissued. Re-privileging
    begins with the licensed health care provider applying through VetPro,
    updating all credentials/certification information, provision of peer
    references, and, again, answering the 17 supplemental/attestation
    questions. The service chief assesses updated information thatmirrors
    items reviewed for the provider�s initial appointment. The service
    chief, along with the credentialing officer, then recommends which
    privileges should be granted/re-granted to the executive committee of
    the medical staff which is chaired by the medical center Chief of
    Staff. The executive committee evaluates the materials to determine if
    medical/clinical knowledge and clinical competence are adequately
    demonstrated to support re-credentialing and the granting of the
    requested privileges. A final recommendation is then submitted to the
    medical center director who is the authority to grant privileges.

                NATIONAL SURGICAL QUALITY IMPROVEMENT PROGRAM (NSQIP)

        NSQIP gathers aggregate data from surgical outcomes to determine
    whether there are significant deviations in mortality and morbidity
    rates for surgical procedures. Since the beginning of Fiscal Year 2007,
    this information is assembled on aquarterly basis. Prior to that time,
    the information had been gathered yearly. It was decided that NSQIP
    would be a better tool if the data were gathered more frequently. This
    was reinforced when our NSQIP data was evaluated after the onset of
    this new timing.
        In response to an elevated ratio of observed to expected surgical
    deaths during the first two quarters of Fiscal Year 2007, a NSQIP team
    conducted an onsite visit at the Marion, IL VAMC. This was conducted as
    part of the NSQIP ongoing program of surveillance of surgical mortality.
    The site visit was conducted in August 2007.
        Following a full and comprehensive investigation of the elevated
    ratio of mortality at the Marion VAMC, the Director took immediate
    action to ensure the safety of patients until the completion of the
    investigation. All in-patient surgery at the Marion VAMC requiring
    general anesthesia was discontinued immediately. Veterans requiring
    surgery with general anesthesia were referred to other VAMCs or, if
    necessary, to non-VA hospitals. VA's Under Secretary of Health (USH)
    directed the VA Office of Medical Inspector (OMI) to conduct an onsite
    visit. On September 5-6, 2007, the OMI conducted a visit at the Marion
    VAMC and confirmed significant issues regarding surgical quality and
    operation and raised issues regarding the management environment at the
    medical center in general. That report is anticipated to be completed
    in the near future. The USH requested the VA Office of the Inspector
    General (OIG) to conduct an onsite visit. Those findings are not final
    at this time. To date, five members of the Marion VAMC staff have been
    reassigned to non-clinical areas away from the medical center or placed
    on administrative leave.
        VA promptly notified Congress of the initial finding identified by
    VA's ongoing assessment and review processes. VA continues to be
    responsive to Congressional inquiries, to the extent possible,
    considering ongoing investigations.

                                  CONCLUSION

        Mr. Chairman, VA has multiple tools in place for assessing and
    evaluating health care and they are working, as in this case, to
    identify irregularities and correct them. These tools are part of the
    ongoing processes that are used in not only revealing the positive but
    also the vulnerabilities and deficiencies in VA's health care system.
    VA acknowledges these findings and seeks to actively address the
    challenges they present. Moreover, the lessons learned are disseminated
    to health care providers throughout our health care system.
        Mr. Chairman, this concludes my statement. At this time I would be
    pleased to answer any questions that you may have.
        Senator AKAKA. Dr. Cross, there are two issues at the heart of the
    situation at Marion. One, did VA do all it could to ensure that
    physicians practicing there were appropriate hires? And, two, when
    deaths and botched surgeries started to arise, did hospital management
    take appropriate action? Are you confident that VA did everything
    possible to verify the credentials of physicians? And are you at this
    point able to say with certainty that hospital management responded
    appropriately when they were told about problems with the surgeon?
        Dr. CROSS. Sir, what I can assure you of is that we have taken
    dramatic, swift, definitive action based on the information we have
    at this time and that we had in August. I am not going to be confident
    to tell you that I have the complete picture until the investigations
    are complete. That does include the medical inspector investigation
    and the IG investigation. But we have found that we have enough
    concerns--we had enough concerns early on in August that we took rather
    definitive action in removing by detailing out the medical center
    director. We detailed out the medical center chief of staff and
    subsequently detailed out the chief of surgery and an anesthesiologist.
        As our investigation has continued, we have taken further action,
    which I have listed in my oral statement elsewhere, and some of that
    just occurring within the past few days.
        Senator AKAKA. Your full statement will be included in the record,
    Dr. Cross.
        Dr. Cross and Ms. Enchelmayer, timing clearly poses a problem in
    the process of background checks. Because medical administrators cannot
    discuss open disciplinary investigations, prospective employees may not
    be aware of serious issues surrounding potential hires.
        The question is: How can the background check process be improved
    to ensure timely and accurate reporting?
        Ms. ENCHELMAYER. I think that I can honestly say that we have a
    credentialing system in VA that is the envy of most of the health care
    industry. We collect a great deal of information on our health care
    practitioners at this time. The application process using the VetPro
    system is an electronic system that actually requires practitioners to
    answer the questions that Dr. Cross alluded to in the opening statement
    about actions in their past�voluntary surrenders because they have
    moved from States, as well as disciplinary actions. And they attest to
    the accuracy of that information as they submit their information to
    us.
        We also ask them for a complete application electronically, which
    includes not only their education and training, but also they are
    requested to provide us information on all current and previously held
    licenses and registrations that they did hold. They must also account
    for all gaps greater than 30 days from the time that they graduated
    from their professional program, which gives us a full background
    history, and we can compare that work history to the information that
    they have provided to us so that is available to the medical staff
    leadership and the staff at the facilities to review.
        We use the secondary flagging systems of the National Practitioner
    Data Bank and Health Integrity and Protection Data Bank, and we
    actually also use the Disciplinary Alert Service at the Federation of
    State Medical Boards, which is not an industry standard. We exceed that
    when we do query the FSMB for information on disciplinary actions on
    physician licensure. And that database has been in existence for many,
    many years. It precedes the National Practitioner Data Bank by a
    significant number of years. So that we do get the disciplinary
    information as well.
        When practitioners submit their information, they actually attest
    to the completeness and accuracy of that information, so it is a legal
    attestation and a legal signature that can be used later if the
    information is not complete.
        And then as Dr. Cross said, all information is primary-source
    verified, and we receive all the information that we can possibly
    receive.
        You asked how we could be helped. The health care industry as a
    whole could be helped because we get the same information every other
    hospital and health care entity gets, and that is public information.
    So we would have to go beyond what all of health care industry gets at
    this time.
        Senator AKAKA. Dr. Cross and Ms. Enchelmayer, it is my
    understanding that doctors' credentials are updated every 2 years when
    reappointment decisions are made. Is there a process in place to ensure
    that credentials are rechecked as soon as new information becomes
    available in national databases regarding disciplinary actions,
    malpractice payments, or license suspensions?
        Dr. CROSS. I will ask Ms. Enchelmayer to expand on this, but I want
    to say yes, and we have involved ourselves with that, taken advantage
    of that, because one of the key credentials is the license itself. And
    if action is taken against a license, we do have a system, wherever
    that action was taken, to notify us.
        Kate, can you expand?
        Ms. ENCHELMAYER. I am happy to, sir.
        VA does subscribe through a contract with the Federation of State
    Medical Boards to the Disciplinary Alert Service. So if a State Medical
    Board takes an action against a license, they report that action to
    their parent organization, the FSMB, and they in turn alert all of the
    member boards, which are 70 osteopathic and medical boards, as well as
    anybody who subscribes to that Alert Service, within 24 hours. I
    personally receive those alerts, and we turn them around to the medical
    centers for immediate processing, and they are to bring the information
    to the attention of medical staff leadership for review and action, as
    well as primary-source verify the information with the State Medical
    Board that led to that action.
        Senator AKAKA. Thank you very much.
        Senator BURR?
        Senator BURR. Thank you, Mr. Chairman.
        Dr. Cross, I will direct my questions to you, but if you would like
    others to answer them, please feel free. I notice that you did not
    mention in your testimony as to whether or not you believe the VA
    credentialing or privileging problems might have led to any of the
    fatalities at the Marion VA facility. Do you believe that the VA
    credentialing or privileging process is at fault?
        Dr. CROSS. I think it is too early for me to assign fault, and I
    think that is where the responsibility will be assigned in the IG and
    the MI investigation. But I do have some concerns. I have concerns that
    we follow through, and that once privileges are granted, that we make
    sure that those privileges remain what is appropriate for that
    individual and that facility.
        Senator BURR. When you say ``appropriate for that individual,'' the
    scope of their--
        Dr. CROSS. The scope.
        Senator BURR [continuing]. Surgical or physician practice?
        Dr. CROSS. Correct.
        Senator BURR. Thank you. Was the VA policy adequately followed at
    the Marion VA facility?
        Dr. CROSS. Based on the knowledge that I have at this time,
    understanding the investigation is continuing, it appears that they
    checked all of the things that I have listed off here, which were the
    appropriate things to do.
        Senator BURR. Do you care to share with the Committee your thoughts
    as to what happened or who might be responsible?
        Dr. CROSS. Sir, I am respectfully not going to try and assign
    responsibility, but I think the focus of our concerns relate to the
    privileging aspect and the monitoring of the privileging and to make
    sure that the staff onsite are well aware of exactly how performance is
    carried out.
        Senator BURR. The Chairman asked a question relative to one's
    privileging and how that might be affected if something new was gleaned
    in that 2-year period. Let me ask a slightly different question. The
    process you go through for credentialing and privileging is a very
    in-depth process that you explained. I would like to hear more about
    how a medical professional already employed by the VA would go about
    maintaining their privileges.
        Dr. CROSS. I will ask Kate Enchelmayer to respond.
        Ms. ENCHELMAYER. I am happy to answer that question, sir. Actually,
    the privileges are granted for a period not to exceed 2 years, but
    throughout that 2-year period, we have many ongoing monitoring
    activities at the local facility level, and that information should be
    being routinely analyzed by the service chiefs who are supervising the
    practitioners on that service and by the executive committee of the
    medical staff and the various committees of the hospital, looking for
    any questions that might arise on a practitioner's clinical practice
    during that period.
        At a minimum, though, every 2 years all the practitioner
    performance data is to be reviewed and is to be analyzed as that
    practitioner renews his or her privileges.
        Senator BURR. Dr. Cross, let me go to that timeline, if I can. I am
    not sure that any of us know exactly what every line means, but let me
    just ask you a question. Given where you start on that timeline, which
    is recognizing in some of the outliers there might be a problem here--I
    take for granted here that is what the first arrow is--and ending with
    the November 1, a general surgeon, an orthopedic surgeon, and another
    surgeon had privileges limited, meaning there has been a review not just
    of a doctor-implicated but the entire medical staff. Do you think that
    the amount of time that it was taking to reach each one of those steps
    is consistent with what we would find in any other medical center in
    the country?
        Dr. CROSS. Sir, I would be very impressed if anyone could have ever
    done it faster. This is a quick response, getting three teams
    assembled, three teams conducting the investigations, and we took
    actions, not waiting for all the teams to come back and report. We took
    actions based on the information that we got early on. That action that
    we took was pretty dramatic in terms of removing from the facility key
    leadership individuals. And we did that early on in that cycle, before
    the IG report came back, before the MI report had been finished. We
    thought that we had enough concern--and we did--to take action to make
    sure that our patients were protected, and we did that early on in the
    cycle.
        I want to emphasize one thing that you asked about. Our
    investigation is not limited to just one individual. We are taking the
    broader picture, checking the entire situation, institution, others,
    taking the broadest possible look to make sure that our patients can be
    reassured.
        Senator BURR. Do you have any concern as the Principal Deputy Under
    Secretary of Health, your title, that the Inspector General is looking
    at this investigation with all the powers his office brings?
        Dr. CROSS. I know the Inspector General and his staff quite well on
    the medical side, and they are focused on detail, and they have
    remarkable determination to get to every one of those details. So, yes,
    I have absolute confidence in them.
        Senator BURR. Thank you, Dr. Cross.
        Dr. CROSS. I also have great confidence in their independence.
        Senator AKAKA. Thank you, Senator Burr.
        Senator DURBIN?
        Senator DURBIN. Dr. Cross, I listened to your description of the
    process that is followed to credential doctors into the VA medical
    system. How much of that decisionmaking and investigation is done at
    the local level by the Marion hospital, for example?
        Dr. CROSS. There are elements of credentialing and privileging that
    are both done at the local level, but privileging is the second phase
    of that, which is almost purely a local process. I will ask Kate to
    correct me if I am wrong.
        Ms. ENCHELMAYER. That is a correct statement. Privileging actually
    has to be facility-based because the privileging process starts with
    what is available at the medical center, and what resources are
    available. And then you start to look at determining what will be
    performed at that facility, which is then followed by matching that
    with the practitioners who will be delivering the care.
        Senator DURBIN. The lengthy and elaborate process that you described
    for credentialing and recredentialing physicians, I am trying to
    understand if that is being done at each of the 150 or so different VA
    medical centers or is being done in some central location?
        Ms. ENCHELMAYER. It is being done at each independent--each
    individual facility because of the fact that the privileging process
    must be done at the local facility level. And the credentials are what
    feed to granting to those privileges to the individual practitioners.
        We implemented in 2001 a standardized electronic credentialing
    system, which does standardize the credentialing process across the
    agency so that the credentialing done in one facility is the exact
    mirror of what is done in every other facility.
        Senator DURBIN. So assuming there is a vacancy for a surgeon in a
    veterans medical center, do I understand then that the local people at
    that medical center get into this process of finding out who is
    available and then determining their qualifications to serve at that
    medical center?
        Ms. ENCHELMAYER. Yes, sir.
        Senator DURBIN. Do I understand that you are promulgating a new
    policy as of October 2nd this year relative to credentialing?
        Ms. ENCHELMAYER. The credentialing and privileging policy is a very
    dynamic policy, and it has been republished numerous times, and, yes,
    the most recent publication was October 2nd.
        Senator DURBIN. What is the most significant change in this new
    approach of October 2nd?
        Ms. ENCHELMAYER. The October 2nd policy actually incorporated a
    number of other directives that we had put in place concerning the
    query to the Federation of State Medical Boards, which was mandated
    back in 2002; expedited credentialing to facilitate the credentialing
    process at the facility level slightly in accordance with the Joint
    Commission standards. It also incorporated some policy on telemedicine
    and teleconsultation, which had been a separate policy. It was a
    unification policy as well as also clarifying a number of issues over
    questions that have been raised for a number of years.
        Senator DURBIN. There is obviously some element of self-reporting
    going on here by the applicants. For example, you have one physician, a
    surgeon, who was put on administrative leave due to failure to disclose
    that he was licensed in a particular State. So I take it that, at least
    at some stage in the process, you depend on the applicant to tell you
    which States he is licensed in.
        Ms. ENCHELMAYER. That is a true statement, sir. We also do have,
    though, in policy a requirement to analyze the work history and to
    determine where somebody practiced and if there was potential for them
    to have a license in a State.
        Senator DURBIN. How long did that particular surgeon practice
    before you discovered that he was licensed in a State he had not
    disclosed?
        Ms. ENCHELMAYER. I did not do the immediate credentialing, sir. I
    cannot answer that.
        Senator DURBIN. Dr. Cross, do you know?
        Dr. CROSS. I will have to get that for the record, sir.
        Senator DURBIN. All right. Let me ask you this: As I read the
    timeline here, I was surprised at a new entry I was not aware of:
    November 1st, a general surgeon, an orthopedic surgeon, and a
    genitourinary surgeon had privileges limited at Marion. So I would like
    to ask you at this point, with the resignation of Dr. Mendez, with the
    administrative leave given to another surgeon for failure to disclose
    his licensure in another State, and now with privileges limited, can
    you give me some kind of a feeling about how many of the surgeons in
    the surgical team at Marion have either resigned, been suspended, or
    have had their privileges limited?
        Dr. CROSS. Sir, to date, five members of the medical center--five
    members of the Marion VAMC staff have been reassigned to non-clinical
    areas away from the medical center or admin leave. Also, a surgeon
    resigned, the original, upon notice of the pending investigation, and
    the VA notified the Illinois Medical Board, as we should have done. We
    did that. And subsequent to the initiation of the investigation, the
    privileges of three other surgeons at the Marion facility have been
    limited, and that is recent.
        Senator DURBIN. What does this tell us about what seems to be a
    comprehensive credentialing and licensing process and the quality
    assurance process that, at a facility like Marion, questions would be
    raised about the disclosures made or practices followed by so many
    surgeons?
        Dr. CROSS. I will start the answer, and I will ask Dr. Almenoff
    to support me on this. But right now, in our reviews, the multiple
    reviews that are being done, they did not dot the ``i'' and cross the
    ``t'' and, you know, we are taking action.
        I will ask Dr. Almenoff to be more specific.
        Dr. ALMENOFF. In total, there were three physicians that were on
    administration leave, and then there are three physicians that are also
    on limited privileges at this point.
        The privileging process at the facility is the heart of what we are
    looking at, at this point. Privileging is really determined at the
    local site, and it is based on the capabilities of the facility, it is
    based on the capabilities of the provider, and it is based on the
    training that they have had in that specific area.
        Senator DURBIN. How many doctors are there in the VA medical
    system?
        Ms. ENCHELMAYER. Thirty-six thousand.
        Senator DURBIN. Is it my understanding that there is some review
    underway for the credentialing of all of these doctors?
        Ms. ENCHELMAYER. Yes, sir. What we did, as soon as this came to
    light, was since we do have an electronic system, we actually looked
    through the system at 56,000 licensed independent practitioners, so
    that goes beyond just the physicians but to anybody practicing
    independently. And we have retrieved 17,000 names that are under review
    right now. These are people who answered the supplemental questions
    yes, and I will tell you my name is in that list because I allowed a
    license to lapse in good standing when I moved from a State, so I
    answered yes to that question, just like a number of other people did,
    and anybody who has a positive answer to a previous disciplinary action
    by a licensing board and anybody who has a report from the National
    Practitioner Data Bank.
        We actually brought in seven field staff to help us initiate the
    analysis, and right now the data is being reviewed at each individual
    facility. We expect to have an initial preliminary review of that data
    by early December with a final report to the Under Secretary by the end
    of December.
        Senator DURBIN. Was this all brought on by the situation in Marion?
        Ms. ENCHELMAYER. Yes, sir.
        Senator DURBIN. So is it fair to say that the Marion situation, as
    tragic as it was, is that the canary in the cage that gave some
    indication to the VA that something needed to be looked into here
    more closely to protect the veterans who were coming in for medical
    care across America?
        Dr. CROSS. Sir, I do not know that the situation in Marion, the
    concerns that we have about the individuals involved, necessarily
    relate to other medical centers, but we are cautious people, and out of
    that caution and care and concern for the patients, we chose to go do
    this very broad review.
        Senator DURBIN. I see my time is up, but I just want to close with
    a comment. It is an interesting system where 150 different hospitals
    are going through this credentialing process, privilege process. I can
    understand that, as it was explained. But it also means it has been
    diffused into a lot of different places and a lot of different people.
    And now that you are doing the review, it is a central review where
    questionnaires are being sent, which leads me to ask whether or not the
    initial credentialing process should have had more central force in it,
    more central involvement so that there are certain standards that we
    can be sure of, whether we are dealing with a rural VA hospital, an
    urban VA hospital, or some particular challenge.
        Thank you.
        Senator AKAKA. Senator Murray?
        Senator MURRAY. Thank you, Mr. Chairman. I was going to ask you
    what assurances we can give our servicemembers that this is not more of
    a systemic failure. I assume your answer would be that you are doing
    this broad review now as a result of what happened at Marion, correct?
    You have 17,000 physicians that you are now going back through and
    looking at.
        Dr. CROSS. Seventeen thousand independently licensed providers, I
    believe, Senator. But there is also one more thing to say. We
    discovered this. It was our internal processes that picked this up. It
    was not some external source that brought this to our attention. And I
    think that should provide at least some reassurance as well.
        Senator MURRAY. I am not sure I understand that. I thought that--
        Dr. CROSS. The internal systems that we have in place.
        Senator MURRAY. But I thought that this came about as a result of
    deaths that occurred at Marion VA.
        Dr. CROSS. Our ability nationwide to pick up those and monitor
    those in terms of national standards is what caused us to trigger the
    investigation.
        Senator MURRAY. Well, can you tell me what some of the reasons are
    that the screening process that was used by the VA could have missed
    the problems that were documented at the other facilities that
    physician worked at?
        Dr. CROSS. I will ask Kate to assist me on this, but my
    understanding--is that the steps that we described here were done.
    Also, we obtained from his State and from his associates and from his
    supervisor letters of recommendation. I believe those letters will be
    part of the ultimate record that is released.
        I should tell you that I can characterize them as being very
    positive, often seeing, you know, the best surgeons, highly technically
    competent; we would hire them back in a minute. And so it was with
    those kinds of references, a full, unrestricted license, 30 years of
    practice, that were factors that came into being at that time.
        Senator MURRAY. So how can we assure that this does not happen
    again?
        Dr. CROSS. Again, responsibility will be assigned, but my focus
    lies with the staff onsite who monitor day to day and who know their
    surgeons, know the cases that they are doing and make judgments about
    the scope of surgery that should be done by that surgeon at that
    location.
        Senator MURRAY. Dr. Cross, can you share with this Committee the
    rate of fatal and non-fatal patient safety events that have occurred at
    the Marion VA since the beginning of 2006 compared with some of our
    other VA hospitals across the Nation?
        Dr. CROSS. I do not think I have that with me, Senator. I can get
    that for the record.
        Senator MURRAY. Does anybody at the table have that? No idea at
    all? If you could share that with the Committee, then, I would
    appreciate it as soon as possible.
        Can I ask you, after the first couple of incidents occurred at the
    Marion VA, why was this physician allowed to continue performing
    surgery?
        Dr. CROSS. I think that is a good question that the IG and the
    medical inspector�s reports will shed more light on. One possible
    explanation is that at the time and at the place where they reviewed
    those cases, they thought there were good explanations that explained
    what had happened.
        Senator MURRAY. OK. Is there anything systematically to review a
    physician after incidences occur? Or is it just kind of haphazard?
        Dr. CROSS. Well, unlike our colleagues in the civilian world, we do
    have an additional safeguard, and that is the NSQIP system. And so even
    if the local safeguards do not work out well, we have a national system
    unlike any others that helps us as an additional safety net.
        Senator MURRAY. How many deaths does it take to activate that?
        Dr. CROSS. It is a statistical�it is not an absolute number. It is
    a statistical technique that is based on comparison to a national
    standard.
        Senator MURRAY. Were the procedures that were being performed
    particularly complex, or were they routine?
        Dr. CROSS. I think some were routine and some were more complex
    than I would have expected.
        Senator MURRAY. I am certain that we will want to review the IG's
    report when it comes out. Let me ask you a more broad question because
    it is one that I think we all need to be aware of, and that is that we
    are really trying to hire more physicians to deal with the high number
    of incoming veterans, both from the current war as well as previous
    wars, and Congress has allocated funds over the last year to do that.
        I am particularly interested in our rural VA facilities where we
    know in the general health care system they already have a hard time
    accessing physicians.
        Should we be concerned that with trying to reach out and hire as
    many physicians as possible, particularly in our rural facilities, that
    we may run into more problems like this?
        Dr. CROSS. Whether the facility is rural or urban, the same
    standards have to apply. I think what changes at a rural facility is
    the scope of surgery that we might do.
        Senator MURRAY. Have the smaller rural VA facilities like the one
    in Marion seen an increasing number of veterans from this current
    conflict?
        Dr. CROSS. They certainly see more, and we have with us today Dr.
    George Maish, from a similar facility in Lebanon, Pennsylvania. Dr.
    Maish?
        Senator MURRAY. Perhaps you could answer what you are seeing at
    your facility.
        Dr. MAISH. Senator, our facility has grown from 1999 to the present
    from taking care of 19,000 individuals to taking care of almost 41,000
    individuals. So we have had to recruit personnel--doctor, nurse, PA,
    nurse practitioner�to care for these people. We are very busy in the
    recruiting business because of the rapid growth in the demand for
    services.
        Senator MURRAY. And you come from a fairly rural facility; is that
    correct?
        Dr. MAISH. I think I would be considered rural. I am in a town of
    about 20,000 in the farming country of Pennsylvania. I am 35 miles from
    Harrisburg, 90 miles to Philadelphia.
        Senator MURRAY. And you have gone from 19,000 in what year?
        Dr. MAISH. 1999.
        Senator MURRAY. More than double today.
        Dr. MAISH. Yes, in an 8-year period, yes.
        Senator MURRAY. I assume, Mr. Chairman, that this is fairly similar
    to what a lot of our rural facilities are facing today. And what has
    been your experience in trying to hire physicians and medical
    personnel?
        Dr. MAISH. It is a difficult job. I run a general surgical
    residency program, and I am integrated into the College of Medicine at
    Hershey Medical Center. Thus, the personnel that I seek to hire, I have
    to be able to present to the College of Medicine to hold an assistant
    professorship. So, I have to look at standards. I have needs. People
    have issues. If you look at my chronology, I graduated high school in
    1960; I graduated from college in 1964; I graduated from medical school
    in 1968; I finished my surgical residency in 1973.
        When I have breaks in that process, I have to ask the practitioner,
    ``Where were you that year? What did you do?'' There are often good
    explanations, and there have been some that were in jail. I dropped
    that process immediately.
        People do not disclose adverse rulings from licensure boards. They
    are instructed by their personal attorney not to, unless they are
    directly asked. I engage this process. I believe the process is
    excellent to screen, but I have to execute my responsibilities in the
    recruiting of new physicians.
        Dr. CROSS. I think, Senator�and Hershey is a growing area, so a lot
    of people have, in fact, turned up in that environment. And to complete
    my answer on one of your other questions, the NSQIP does cover all of
    our hospitals where we do surgery, including rural.
        Senator MURRAY. OK. Well, I think, Mr. Chairman, my point is that
    we are seeing an increased intensity and need in our VA facilities
    across the country. In our rural and in our urban, but in our rural
    hospital facilities in particular, they are trying to recruit very
    fast. That means we have to be even more diligent in checking
    credentials because, as we all know, that is when people start
    slipping through the cracks. And I look forward to the hearing that I
    hope we will have once the IG report is complete, and I hope that the
    VA can come to us and really talk to us about what they are doing,
    particularly in these communities, to make sure that we get the best,
    the brightest, and those who are credentialed and safe to per form
    surgery.
        Thank you very much.
        Senator AKAKA. Thank you, Senator Murray.
        I want to thank the first panel. Dr. Cross, what you said is
    something that is of paramount importance for us--the well-being of our
    patients. That is why we are here--the VA patients. I primarily wanted
    to focus today on the hiring practices and quality control as well as
    the credentials of those who serve in those areas. And we want to fix
    any problems. And so I hope what is happening today will result in
    that.
        May I call on Senator Durbin?
        Senator DURBIN. Dr. Maish, I am not sure if this question is for
    you or for Ms. Enchelmayer or Dr. Cross, or perhaps all of you. In
    this particular case, this doctor surrendered his license in the State
    of Massachusetts and was characterized by the State as having done so
    for a non-disciplinary reason. And the explanation, I understand, I
    gave earlier, that he was no longer going to practice there and so
    forth.
        I would like to ask you: Is that the kind of thing that would raise
    a question in your mind even if it were characterized as
    non-disciplinary?
        Dr. CROSS. Sir, it raised the question in our minds as well and in
    the staff there. I do have to be precise. He did not relinquish his
    license. It is a technicality, but he agreed to not practice in the
    State. He still had a license. And the response by our staff, as I
    understand from the preliminary medical inspector's report, is that
    they thought that was of concern as well and actually called to the
    State of Massachusetts to get more information.
        Senator DURBIN. And did they get more information?
        Dr. CROSS. The only information they got was the words ``it was
    a non-disciplinary action.''
        Senator DURBIN. Well, the first time you explained that to me all
    the red flags started to wave. I know as a lawyer, it looks like there
    was an agreement reached here: We are not going to take your license
    away, but we do not want you practicing in this State. We will put it
    down as non-disciplinary and that will be the end of it, but don't come
    around here anymore. And the lawyer may have said, ``Let's get out of
    here. You can still practice at the VA facility in Marion. You still
    have an Illinois license. Let's move on.''
        Now, maybe that is a cynical view, but with the limited information
    which you have, it could also be an accurate view. And I would say,
    Dr. Maish, as you went through step-by-step and day-by-day, this was a
    suspicious thing that occurred, and had action been taken at that
    point, it would have been taken before many of these fatal surgeries.
        Senator AKAKA. Well, again, I want to thank our first panel for
    your testimony and for your responses.
        Senator AKAKA. I will now introduce the second panel. I want to
    extend my warm welcome and my warm aloha to the second panel. I
    appreciate each of you being here today and look forward to your
    testimony.
        First, I welcome Randall Williamson, who is Director of Health
    Care for the GAO.
        I also welcome Tammy Duckworth, Director of the Illinois Department
    of Veterans' Affairs. Ms. Duckworth has testified before this Committee
    twice before, most recently during our hearing last March, which
    examined health care services for returning servicemembers. I am happy
    to see you again, Tammy.
        I also welcome Steven McCarty, a veteran from Bedford, Texas.
    Mr. McCarty served in Iraq in 2006 and 2007, and thank you for making
    the trip to testify today.
        Each of your statements will appear in the record of today's
    hearing, and I ask that you each limit your direct testimony to no more
    than 5 minutes so that we have time for questions.
        Mr. Williamson, will you please begin with your testimony?

               STATEMENT OF RANDALL B. WILLIAMSON, ACTING DIRECTOR,
                 HEALTH CARE, U.S. GOVERNMENT ACCOUNTABILITY OFFICE

        Mr. WILLIAMSON. Thank you, Mr. Chairman and Members of the
    Committee. I am pleased to be here today to discuss our May 2006 report
    on VA's processes for credentialing and privilegingVA physicians. Since
    Dr. Cross has already given you a fairly detailed overview of VA's
    credentialing and privileging process, I am going to limit my remarks
    today to the findings of our 2006 report on compliance with these
    processes at VA facilities we visited. I will also discuss the action
    VA has taken on the recommendations we made to improve the privileging
    process. For this work, we visited seven VA facilities, reviewed
    physician files, and interviewed VA officials as these facilities and
    at VA headquarters.
        At the facilities we visited in 2006, we found that all seven
    facilities were complying with the key credentialing requirements that
    we examined, including requirements to verify physicians' State medical
    licenses, to verify information provided by physicians on their
    involvement in malpractice claims, and to query available databases to
    determine physicians' involvement in disciplinary actions and
    malpractice claims. We also looked at compliance with privileging
    requirements, including whether facilities were verifying physicians'
    training and experience, assessing physicians' clinical competence and
    health status, and considering a physician's performance while at VA
    when renewing his or her clinical privileges. While the seven
    facilities were complying with most of the privileging requirements we
    examined, we noted compliance problems with certain aspects of
    privileging.
        First, we found that six facilities were not using or obtaining
    appropriate data to evaluate physicians� performance while at VA. The
    seventh facility was not using any physician performance data in making
    its privileging decisions for reappointment of physicians.
        Second, three of the seven facilities were not forwarding
    information within the required 60 days on paid VA medical malpractice
    claims to a VA office that makes determinations on whether substandard
    care has occurred. Delays in providing this information could prevent
    determinations of substandard care by physicians from being considered
    as part of the facility's privileging process.
        Finally, we found that one facility we visited lacked internal
    controls that would have helped identify that the privileging process
    had not been completed for 106 of its physicians within the 2 years
    required. As a result, these physicians were practicing at the facility
    with expired clinical privileges. None of the other six facilities we
    visited had internal controls in place that would have prevented a
    similar situation from occurring.
        We made recommendations to improve VA's physician privileging
    process and to remedy each of the three problem areas that we found. VA
    concurred with our findings and recommendations and reported that it
    has implemented measures to improve its privileging process. However,
    we have not visited or examined records at VA facilities since 2006 to
    determine whether these improvements are in place and whether VA
    facilities are complying with the current credentialing and privileging
    processes.
        VA's privileging improvements include:
        (1) a policy issued last month elaborating on the appropriate types
    and sources of physician performance information that could be used by
    its medical facilities during the privileging process.
        (2) stricter procedures to enforce prompt reporting of information
    about paid malpractice claims, including notification to medical
    facility directors and VA headquarters about delinquencies.
        (3) establishment of internal controls to ensure that privileging
    information is kept accurate and current at its facilities.
        Mr. Chairman, this concludes my statement. I would be happy to
    answer any questions that you or other Members may have.
        [The prepared statement of Mr. Williamson follows:]

                   PREPARED STATEMENT OF RANDALL B. WILLIAMSON,
                         ACTING DIRECTOR, VA HEALTH CARE

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        Senator DURBIN [Presiding]. Secretary Duckworth, you are next
    to testify. Glad to see you here.

             STATEMENT OF TAMMY DUCKWORTH, DIRECTOR, ILLINOIS
                      DEPARTMENT OF VETERANS' AFFAIRS

        Ms. DUCKWORTH. Well, I would like to thank my Senators, Senator
    Durbin and Senator Obama, for their aggressive actions leading to the
    examination that we are now seeing at the Marion VA Medical Center.
    Senator Durbin and Senator Obama have long been advocates of veterans
    here in Illinois.
        I would like to have my additional comments added to the record
    from the written statement.
        Senator DURBIN. Without objection.
        Ms. DUCKWORTH. My biggest concern, sir, is that there is a lack of
    consistency across the Nation when it comes to the local level for
    implementing many of the VA's national programs, and I am seeing this
    in our rural communities especially, specifically Danville VA and
    Marion VA. Both are in rural central and southern Illinois.
        The problem that we have is that whether it is a policy of allowing
    veterans to access outside physicians or whether it is this
    credentialing issue, there is a national policy, but it is selectively
    enforced at the individual medical center level. I will give you an
    example with Danville VA.
        Many of the patients at Danville VA actually have to travel upwards
    of 3 to 4 days just to get a simple chest x-ray, while there are
    doctors and physicians near their home towns where they can actually
    get these procedures completed without having to spend multiple
    overnights. The Danville VA is very reluctant to allow the patients in
    its community to access their outside health care, even though a
    procedure already exists for them to do so in the Federal VA system. So
    while there is great national policy and procedures written someplace
    in a manual, oftentimes it is the local administrators, the local
    hospital administrators, who interpret those policies who do not
    actually administer them.
        The timeline that we saw earlier today gives me great concern
    because we are so focused on what happened after the ten deaths
    occurred, we are not looking at what happened up to that point. Did the
    local facilities actually implement those processes, those wonderful
    processes that actually lead the Nation in terms of credentialing? I am
    also additionally concerned with the fact that a doctor in the Marion
    VA does not have to hold a license in Illinois to practice in Illinois.
    That is a great concern to me. I know that in our four nursing homes
    that we operate by the State of Illinois for veterans, our doctors that
    operate there hold licenses in Illinois and also have privileges at the
    local hospitals outside of our own system. So that there is some sort
    of a cross-check, not only of we verifying them but they also hold
    privileges at the local community hospitals as well, who also go
    through their own process of verifying the credentials of the
    physician.
        Throughout this, I think it is important to say that I do not ask
    for any shutdowns of any rural VA's. In fact, we need more VA hospitals
    and clinics, especially in our rural communities. In Illinois alone,
    over 50 percent of our recruits come from areas outside Chicago's Cook
    and collar counties, and we are seeing an increased rise in veterans'
    needs, not just from the young veterans coming home from Iraq and
    Afghanistan. The Federal VA estimates that there are approximately
    8,122,000 Vietnam veterans who are now entering their mid-60's, at a
    point when their medical needs increase.
        Many of the illnesses, such as those caused by Agent Orange, are
    just now appearing in their system-leukemia, cancers, those types of
    things. There is going to be a greater demand for more complex
    procedures for older veterans, and this is happening across the Nation.
        As a percentage of that 8 million veteran number, I am estimating
    that Illinois alone has approximately 389,000 Vietnam veterans. Many of
    these veterans have not accessed VA care up until this point. Many of
    these veterans live a long way away from the nearest VA clinic or
    hospital.
        So I would like to just summarize my testimony by saying that some
    of the suggested solutions are that the USDVA needs to either open more
    VA clinics and Vet Centers, or they need to start certifying private
    practitioners to provide medical services and give the veteran this
    option to access care outside of the VA clinic or the VA hospital
    themselves. We need to ensure, however, that there is no drop in
    standard of care for our veterans. We also need to identify major
    civilian medical facilities, such as university teaching hospitals or
    other large networks, where the physicians who have privileges at the
    VA hospital should be required to also have privileges, surgical
    privileges, practice privileges as these outside facilities to provide
    a cross-check, as it were. Not only is there a VA system that is being
    implemented by the local VA hospital administrator, but if that
    physician is required to have a licensing requirements in the State
    where he is practicing, as well as privileges at an outside hospital, I
    hope that will help to reinforce and provide a back-up.
        There simply is just not enough time for the USDVA to try to
    recruit enough physicians to meet the current need, and I think that it
    is time to think a little outside the box. And I thank you for calling
    this hearing, even at this early stage, because I think it will allow
    us to move forward in terms of future questions that need to be raised.
        I want to say, Senator Akaka, that it is great to see you in that
    chair, sir. Thank you.
        [The prepared statement of Ms. Duckworth follows:]

                PREPARED STATEMENT OF TAMMY DUCKWORTH, DIRECTOR,
                  ILLINOIS DEPARTMENT OF VETERANS' AFFAIRS

        Mr. Chairman, Members of the Committee. It is a pleasure to be
    asked to testify before you today on behalf of Illinois Governor Rod
    Blagojevich and the Illinois Department of Veterans' Affairs. This
    Committee is to be commended for drawing attention to the very
    important issue of quality of care for our returning Veterans and servicemembers.
        I want to thank my Senator, Senator Durbin, for his aggressive
    action which led to the examination we are now seeing at the Marion VA
    Medical Center. Sen. Durbin has long been an advocate for Veterans and
    their care.
        The Illinois Department of Veterans' Affairs assists Illinois'
    Veterans in obtaining their State of Illinois Veterans' benefits as
    well as their Federal Veterans' benefits.
        We have 74 Veterans Service Officers on staff who are certified by
    the U.S. Dept. of Veterans' Affairs (USDVA) to process, represent and
    make appeals on behalf of the Veteran in their claims for compensation
    from the USDVA. State of Illinois benefits for Veterans are in addition
    to Federal benefits and range from generous educational, mortgage loan,
    and other financial assistance to our four Veterans' Homeswhere
    Illinois' Veterans may live out their remaining days with the dignity
    and care they deserve. As the Director of this agency, I want to be
    clear that we do not have any jurisdiction over the USDVA's operations,
    to include the various USDVA Veterans' clinics, hospitals and Vet
    Centers.
        While we may not have the responsibility of licensing and
    overseeing the actual hiring of doctors for the Federal facilities in
    Illinois, we do work closely with all our Veterans and try to find the
    most reasonable and highest quality health care accommodations
    available.
        As the Director of IDVA, I see every day the struggles of families
    as they prepare to drive long distances to a health care facility.
    These struggles impact spouses, parents, and children. And when in a
    rural area, these drives and travels take a further toll on our
    servicemembers and Veterans. We cannot afford to have doctors who are
    not suited for license practicing medicine in any of our facilities.
    And we cannot have disparities in the quality of care that is provided
    at our rural and urban facilities.
        Statistics vary on the actual number of U.S. military recruits from
    rural communities, but they all indicate that a disproportionate
    percentage of our all-volunteer military are from rural areas, and thus
    a disproportionate share of deaths and injuries are occurring within
    our rural recruit population. In Illinois, over 50 percent of our
    military recruits entered the service from a county outside the city of
    Chicago's Cook and collar counties. As such, maintaining facilities
    such as Marion, yet improving the quality of care provided, is
    essential to DOD's and the VA's ability to care for our Soldiers once
    they return home from their service to our Nation.
        In Illinois we have a significant rural population who live a long
    distance away from the nearest metropolitan area where the USDVA
    typically locates its Veterans servicecenters, clinics and hospitals.
    This poses a significant access issue for our Veterans. Accordingly,
    the IDVA has responded by opening 51 offices throughout the state to
    provide Veterans with a location to obtain assistance in applying for
    their USDVA benefits. Once approved, however, Veterans still often have
    to travel a long distance in order to obtain care, often involving
    multiple overnights away from homeas they wait for the various
    once-a-day shuttle bus services. It is normal for a Veteran in central
    Illinois to have to travel fours days away from home roundtrip, for a
    single doctor's visit, sometimes for a procedure as simple as an x-ray.
        More personally, as an injured Veteran I�ve seen first hand what it
    is like to receive care in our VA system. In particular, I want to
    highlight the stresses of traveling to get care as well as the impacts
    that these stresses have on the families of Veterans. I can attest to
    the hardship on my family and employer. I live in suburban Chicago. To
    access my VA hospital basically takes an entire day off from work
    because of the long drive times as well as the common experience of
    long waiting times to see medical professionals, obtain pharmacy
    services, etc. Now, I'm the Director of a state Veteran's agency. I
    would not be surprised if I routinely receive more conscientious
    service than most. If I find some of these things challenging or
    difficult, imagine how a 20-year-old Soldier who has never interacted
    with the system feels. Not to mention, how does a 70-year-old Veteran
    who can no longer drive obtain the services that he earned and now
    needs?
        The VA system faces new challenges as a result of the wars in Iraq
    and Afghanistan. The patient profile in the VA is changing. More
    wounded Soldiers are surviving very serious injuries. We face new types
    of injuries, such as Traumatic Brain Injury and an increase in poly
    trauma cases as well as servicemembers facing Post Traumatic Stress
    Disorder. With the all-volunteer military, we are now seeing a much
    larger patient load that is geographically disbursed around our
    country.
        With these new demands, the VA hospitals will be under increased
    pressure to find more doctors to deliver quality care. I repeat,
    QUALITY care. The VA must ensure that its hiring procedures do not
    allow anyone to cut corners and compromise excellence as hiring is
    ramped up. That pressure is likely to be most acute in hospitals
    located in rural and underserved areas. The VA must put procedures in
    place to ensure that only qualified doctors are hired and that these
    medical professionals are given the cultural training that comes with
    the unique culture of the military.
        At the end of his life my father could be a difficult patient.
    However, if a doctor called him by his military rank and told him there
    were lower ranking Vets who were ill and needed to have priority over
    him, my dad would have gladly slept in the hallway to make sure that
    the lower ranking Soldier was cared for.
        Our VA medical system must meet the challenge our young Veterans'
    have as they return with new needs and at the same time it must expand
    its services to meet the demand of the boom in Vietnam Veterans
    re-entering the VA system. Many of these Vietnam Vets have not used VA
    services previously, but are now entering their mid-60's with all the
    associated diseases and illnesses that comes with their age. We are
    also dealing with injuries that have taken over 30 years to develop,
    such as cancers, diabetes and other conditions that result from
    exposure to Agent Orange. According to the State of Aging and Health in
    America 2007 Report, the cost of providing health care for an older
    American is three to five times greater than the cost for someone
    younger than 65.
        So the USDVA is now faced with our young servicemembers returning
    home and entering the VA medical system at the exact same time that the
    medical needs ofour Vietnam Veterans will be increasing. The amount of
    money this is going to cost the Nation and each individual state is
    tremendous. In addition, we don't have enough room at our
    facilities--state or Federal--to take care of both eras at once. The
    dedicated staff at the USDVA medical hospitals is already overworked
    and understaffed. Let me give you an example: The USDVA estimates that
    there are 8,122,000 Vietnam era Veterans in this country. I estimate,
    based on percentage of Veterans in Illinois that we are home to 389,856
    Vietnam Veterans. The Illinois Department of Veterans' Affairs operates
    four state Veteran homes, which are long-term care facilities. Our
    1,000 beds are almost at full capacity and already house 100 Vietnam
    Veterans. The number of Vietnam Veterans seeking to enter our Veterans'
    homes will only increase as will the number on the waiting list. In
    response, we are in the planning stages to build another new Veterans'
    home. The fact is thatright now most VA systems, at the state or the
    Federal level, are not ready to handle both eras' Veterans entering the
    VA system at the same time. Illinois is working to be ready with the
    first of the expansions to our Veterans Homes opening next summer and
    by investing over $50 million in new programs aimed at young Veterans
    in just 2007 alone.
        What the USDVA needs is to either open more VA clinics and Vet
    Centers or to certify private practitioners to provide medical services
    and give the Veteran this option. While there is already a system in
    place within the USDVA for Veterans to use private medical care
    facilities, this system is uneven across the Nation. In central
    Illinois, the Danville VA facility is so unyielding that it actually
    forces its Veterans to endure overnight travel to get a simple x-ray
    performed instead of using a local clinic minutes away from their home.
    By identifying major civilian medicalfacilities, such as University
    teaching hospitals or other large networks, the USDVA could ensure that
    our Veterans receive the needed quality care that they deserve. I must
    caution, however, that any privatization of VA care be conducted with
    extreme supervision to insure that there is no lowering of standards
    and quality of care for our Veterans.
        An additional way that the USDVA is not ready to handle our
    Veterans' needsis in technology. The USDVA has superior expertise in
    many areas and can meet Veterans' needs if the Veteran can afford to
    travel to the appropriate VA facility. However, in other areas, the VA
    is far behind current developments and will be unlikely to catch up and
    adequately meet Veterans needs at the same time. For example, in the
    case of prosthetics, the VA is not ready and our Veterans cannot afford
    to wait for them to play catch-up. My VA hospital, Hines, is superior
    in blind and spinal cord rehabilitation, but the prosthetics
    department, while eager to meet my needs, is many decades behind in
    prosthetics technology. I now receive care at Hines for my primary
    medical care, but also continue to return to Walter Reed for
    prosthetics--paying for my own travel costs. I also travel to a
    specialist in Florida for state-of-the-art care. Recently, Hines sent a
    prosthetist with me to Florida to learn about the high-tech artificial
    legs that I obtain from the private practitioner there. He was
    overwhelmed by the technology and the civilian practitioner was
    appalled at the lack of current knowledge shown by the Hines
    representative. The USDVA is absolutely not ready to treat amputee
    patients at the high-tech levels set at the DOD medical facilities.
    Much of the technology is expensive and most of the VA personnel are
    not trained on equipment that has been on the market for several years,
    let alone the state-of-the-art innovations that occur almost monthly in
    this field. I recommend that the VA expand its existing program that
    allows patients to access private prosthetic practitioners. There is
    simply not enough time for USDVA to catch up in this field in time to
    adequately serve the new amputees from OIF/OEF during these critical
    first 2 years following amputation. Perhaps after the end of the
    current wars in Iraq and Afghanistan, the VA will have time to advance
    its prosthetics program.
        I've appeared before both the U.S. Senate Committee on Veterans'
    Affairs and the House Subcommittee on Veterans' Affairs to testify on
    the seamless transition from DOD to VA health care and have presented
    several recommendations to improve the health care services for our
    Nation's Veterans. For instance, I recommended that any seamless
    transition program must also include comprehensive screening for
    Traumatic Brain Injury (TBI), Post Traumatic Stress Disorder (PTSD) and
    vision loss by both the DOD and the USDVA Health Care systems.
        I want to highlight how Illinois is addressing TBI and PTSD. Over
    the past summer, Illinois announced the Nation�s first-of-its-kind
    program to screen every Illinois National Guard member for Traumatic
    Brain Injury while offering free TBI screening to all other Illinois
    Veterans. As part of this program, Illinois is also establishing a
    24-hour, toll-free hotline to provide psychological assistance to
    Veterans suffering from Post Traumatic Stress Disorder. When a Veteran
    calls this hotline, a clinician performs an initial over-the-phone
    screening and determines the next steps to take. All staff will be
    trained in the area of combat-related PTSD and other mental issues
    faced by Veterans, and there is at least one psychiatrist on call at
    all times. The hotline format is important, as our Veterans often do
    not have the option or willingness to drive 100 miles for PTSD
    treatment. When one wakes up from a nightmare at 2 a.m. on a Friday
    night, one needs help immediately, not at 8 a.m. on the following
    Monday, which is the current case with the USDVA. I know that efforts
    are underway to strengthen these assessments by both the DOD and the
    USDVA. However, there is no standard procedure in place to insure that
    all returning servicemembers are screened nation-wide.
        I commend this panel for its oversight of the U.S. Veterans
    Administration and the facilities that it operates. We should all
    demand that our Veterans have access to care that is commensurate to
    their dedication to our country.
        I would be happy to take any questions.
        Senator AKAKA [Presiding]. Thank you.
        Mr. McCarty?

                 STATEMENT OF STEVEN MCCARTY, VETERAN, OPERATION
                       IRAQI FREEDOM, BEDFORD, TEXAS

        Mr. MCCARTY. Mr. Chairman, thank you for the opportunity to
    testify today before the Veterans' Affairs Committee. I look forward to
    sharing my story with the Senators here this morning.
        My name is Steve McCarty, and I am a Lance Corporal with the
    United States Marine Corps Reserve with the 14th Marines Headquarters
    Battery out of Fort Worth, Texas. On June 1, 2006, I was part of a
    detachment that was activated with 1st Marines 24th Division. We were
    sent to Fallujah, Iraq, from September 24, 2006, to April 15, 2007.
    During this time I served as a member of a truck platoon.
        In February of this year, while I was still in Iraq, I was
    concerned when I started experiencing diarrhea with blood in the stool.
    When I confronted my corpsman, he gave me the option to either keep
    going and do the missions or go to medical and receive treatment and
    possibly miss operations. I chose to keep going.
        Upon returning from Iraq in April, the stress of demobilization and
    jubilation of getting reacquainted with family and civilian life
    overshadowed the discomfort of my symptoms, which seemed minor at the
    time. While driving home from visiting my grandmother in Indiana, my
    symptoms got to the state where they could no longer be ignored. I was
    in severe pain, had bad diarrhea, and was vomiting. My parents were now
    aware of my deteriorating health and convinced me to stop at the VA
    Hospital in Marion, Illinois.
        Upon arriving at the emergency room, the doctor ran various tests,
    which included blood work and a CAT scan. The results of these tests
    were negative. At this time, the ER doctor, who was a surgeon, admitted
    me and diagnosed my symptoms as possibly being appendicitis. He
    recommended removing the appendix and doing exploratory surgery. After
    he consulted with other doctors, some of which did not agree with this
    diagnosis, he took the advice of a second surgeon who recommended doing
    the surgery laparoscopically. We were more comfortable with this
    technique due to the shorter recovery time and lack of a large
    incision. The doctors thought I would be ready to leave the hospital in
    a few days.
        I had surgery at the Marion VA on Friday, June 15th. After the
    operation, we were told that the appendix did not look as bad as what
    they anticipated. Although I had been suffering for 4 months, the
    surgeon thought I must have a virus since the antibiotics were not
    having any effect.
        On Sunday, 2 days after the surgery, my symptoms were getting
    worse. However, the doctors continued to follow the timetable and
    release after having your appendix removed. At this point one of the
    nurses told my parents that she would get me out of there if I were
    her son. She said the doctors did not know what was wrong with me.
        Seeing my deterioration, my parents began asking for specialists on
    Monday, June 18. They were told the specialists were part of the clinic
    and were not available to attend to hospital patients. After receiving
    outside advice, my parents spoke with the patient advocate at the
    hospital. We were told that there was not a gastroenterologist, but an
    infectious disease specialist was available.
        Four days after my surgery, my stomach still swollen and the other
    symptoms still there, an infectious disease specialist finally came to
    see me. Within minutes, he diagnosed me with dysentery and changed my
    antibiotic, but he could not explain my swollen stomach. I honestly
    looked like I was 9 months pregnant. That night my mom asked a nurse
    about this, and she said she had never seen it last this long. Another
    nurse told us that she would never take her family to any doctors
    there. They go to doctors in St. Louis, Missouri--a 2-hour drive from
    Marion.
        After 7 days at the Marion hospital, my condition had stabilized
    enough for me to attempt to travel, and my parents asked for assistance
    in getting me quickly and safely home. The only assistance given to us
    was the cost of one ticket for the shuttle that runs from Marion to the
    St. Louis airport. When I was discharged, I was supposed to take the
    new antibiotic, but they mistakenly gave me the old and less effective
    one.
        Upon returning home to Texas, my close Marine buddy informed us
    that we still had TRICARE coverage. The morning after returning from
    Illinois, we went to the emergency room at Harris Methodist H-E-B
    Hospital. The doctor noticed the severity of my symptoms and did all
    the same tests I had received at Marion. Upon reviewing the test
    results, the ER doctor discovered that my colon was perforated and I
    had free air under my diaphragm. My waste was pouring into my abdominal
    cavity. The ER doctor immediately called in the specialists.
        I was taken to surgery that afternoon. Two sections of my colon had
    to be removed. These two sections were in the same location as two of
    the laparoscopic incisions. Due to the severity of the infection, my
    wound had to be left open. After the surgery, the doctor told my
    parents I was lucky to be alive. If it had not been for the fact that I
    was in such good shape and young, I would be dead.
        I spent the next 3 weeks in the hospital and was discharged on
    July 11, 2007. I was attached to a wound vac for 6 weeks. Now I have
    both a colostomy and ileostomy bag. The doctors at Harris Methodist
    H-E-B Hospital finally diagnosed my symptoms I had been experiencing
    since my service in Iraq as ulcerative colitis--a condition that would
    have been seen earlier if a colonoscopy would have been performed.
        This has affected the quality of life for me and my family. This
    has prevented me from drawing unemployment and working. It is also
    hindering my advancement in the military. I have no source of income,
    and I am told it will take 1 year for the VA to process my disability
    requests. I have applied for incapacity pay, but have not received
    anything to date.
        In closing, I have a colostomy bag, an ileostomy bag, a large open
    wound, and multiple laparoscopic incisions. I will be unable to
    effectively serve in the Marines at home as well as unable to deploy.
    The actions of the VA hospital in Marion have removed this Marine and
    countless other veterans from the war on terror. These wounds are not a
    result of insurgents; they are a result of incompetence on American
    soil.
        Thank you for allowing me to share my story today. I am happy to
    answer any questions about my experience.
        [The prepared statement of Mr. McCarty follows:]

                 PREPARED STATEMENT OF STEVEN MCCARTY, VETERAN,
                         OPERATION IRAQI FREEDOM

        Mr. Chairman, thank you for the opportunity to testify today before
    the Veterans; Affairs Committee. I look forward to sharing my story
    with the Senators here this morning.
        My name is Steve McCarty and I am a Lance Corporal in the U.S.
    Marine Corps Reserve with the 14th Marines Headquarters Battery out of
    Fort Worth, Texas. On June 1, 2006, I was part of a detachment that was
    activated with 1st Marines 24th Division. We were sent to Fallujah,
    Iraq from September 24, 2006, through April 15, 2007. During this time
    I served as a member of a truck platoon, primarily driving a 7&fxsp0;-ton
    refueling truck.
        In February of this year, while I was still in Iraq, I was
    concerned when I started experiencing diarrhea with blood in the stool.
    My symptoms were consistent with what has since been diagnosed as
    ulcerative colitis. When I confronted my corpsman, he gave me the
    option to either keep going and do the missions or go to medical and
    receive treatment and possibly miss operations. I chose to keep going.
        Upon returning from Iraq in April, the stress of demobilization and
    jubilation of getting reacquainted with family and civilian life
    overshadowed the discomfort of my symptoms which seemed minor at the
    time. After being deactivated off of active duty on June 1, my family
    and I traveled to the Midwest. While driving home from visiting my
    grandmother in Indiana, my symptoms got to the state where they could
    no longer be ignored. I was in severe pain, had bad diarrhea, and was
    vomiting.
        My parents were now aware of my deteriorating health and convinced
    me to stop at the VA Hospital in Marion, Illinois.
        Upon arriving at the emergency room, the doctor ran various tests
    which included blood work and a CAT scan. The results of these tests
    were negative. At this time, the ER doctor, who was a surgeon, admitted
    me and diagnosed my symptoms as possibly being appendicitis. He
    recommended removing the appendix and doing exploratory surgery. After
    he consulted with other doctors, some of which did not agree with the
    diagnosis, he took the advice of a second surgeon who recommended doing
    the surgery laparoscopically. We were more comfortable with this
    technique due to the shorter recovery time and lack of a large
    incision. The doctors thought I would be ready to leave the hospital in
    a few days.
        I had surgery at the Marion VA on Friday, June 15. After the
    operation, we were told that the appendix did not look as bad as they
    had anticipated. Although I had been suffering for 4 months, the
    surgeon thought I must have a virus since the antibiotics were not
    having any effect.
        On Sunday, 2 days after the surgery, my symptoms were getting
    worse. In addition, my stomach was now swollen. However, the doctors
    continued to follow the timetable for recovery and release after having
    appendicitis. At this point one of the nurses told my parents that she
    would get me out of there if I were her son. She said the doctors did
    not know what was wrong with me.
        Seeing my deterioration, my parents began asking for specialists on
    Monday, June 18. They were told the specialists were part of the clinic
    and were not available to attend to hospital patients. After receiving
    outside advice, my parents spoke with the patient advocate at the
    hospital. We were told there was not a gastroenterologist, but an
    infectious disease specialist was available.
        Four days after my surgery, my stomach still swollen and the other
    symptoms still there, an infectious disease specialist finally came to
    see me. Within minutes, he diagnosed me with dysentery and changed my
    antibiotic, but he could not explain my swollen stomach. I honestly
    looked like I was 9 months pregnant. That night my mom asked a nurse
    about this and she said she had never encountered a situation like
    this. Another nurse told us that she would never take her family to any
    doctors there. She goes to doctors in St. Louis, Missouri--a 2-hour
    drive from Marion.
        After 7 days at the Marion VA, my condition had stabilized enough
    for me to attempt to travel and my parents asked for assistance in
    getting me quickly and safely home. The only assistance given was the
    cost of one ticket for the shuttle that runs from Marion to the St.
    Louis airport. When I was discharged, I was supposed to take the new
    antibiotic with me but they mistakenly gave me the old and less
    effective one.
        Upon returning home to Texas, my close Marine buddy informed us
    that we still had TRICARE. The morning after returning from Illinois,
    we went to the emergency room (ER) at Harris Methodist H-E-B Hospital.
    The doctor noticed the severity of my symptoms and did the same tests I
    had received in Marion. Upon reviewing the test results, the ER doctor
    discovered that my colon was perforated and I had free air under my
    diaphragm. My waste was actually pouring into my abdominal cavity. The
    ER doctor immediately called the specialists.
        I was taken to surgery that afternoon. Two sections of my colon had
    to be removed.
        Those two sections were in the same location as two of the
    laparoscopic incisions. Due to the severity of the infection, the wound
    had to be left open. After the surgery, the doctor told my parents I
    was lucky to be alive. If I hadn't been in such good shape and young, I
    would be dead.
        I spent the next 3 weeks in the hospital and was discharged on
    July 11, 2007. I celebrated my birthday while still in the hospital. I
    was attached to a wound vac for 6 weeks. I now have both a colostomy
    bag and ileostomy bag. The doctors at Harris Methodist H-E-B Hospital
    finally diagnosed the symptoms I had been experiencing since my service
    in Iraq as ulcerative colitis. The part of my colon that remains is not
    functional at this time.
        This has affected the quality of life for me and my family. This
    has prevented me from drawing unemployment and working. It is also
    hindering my advancement in the military. I have no source of income
    and I am told it will take 1 year for the VA to process my disability
    requests. I have also applied for incapacity pay but have not received
    anything to date.
        In closing, I have a colostomy bag, an ileostomy bag, a large open
    wound, andmultiple laparoscopic incisions. I will be unable to
    effectively serve in the Marines at home as well as unable to deploy.
    The actions of the VA hospital in Marion have removed this Marine and
    countless other veterans from the war on terror. These wounds are not a
    result of insurgents, they are a result of incompetence on American
    soil.
        Thank you for allowing me to share my story today. I am happy to
    answer questions about my experience.
        Senator AKAKA. Thank you, Mr. McCarty.
        Senator Durbin?
        Senator DURBIN. I would like to thank Chairman Akaka for allowing
    me to ask first. I have to go down to a Senate Judiciary Committee
    meeting. My thanks to the panel, each one of you.
        First, to Lance Corporal McCarty, who came by my office yesterday
    with his family, this is a heart-breaking story of a young man with a
    medical problem whose treatment was inappropriate and which led to
    complications, pain, hospitalization, and your life has changed. That
    is the reality when serious mistakes are made. I am certain that your
    case will be investigated, as it should be, and I stand ready to help
    you in any way that I can. You served your country. Now we need to
    serve you. And thank you for being here today and telling your story. I
    know it was not easy, but it is important that it be heard. It is a
    reminder that a lot of things that we are talking about here involve
    real human lives, the lives and the futures of our veterans like Steven
    McCarty. So, thank you so much for being here.
        To Tammy Duckworth, let me just say that there are probably very
    few people in America better qualified than you to talk about the
    treatment of soldiers and veterans after your experience serving in
    Iraq and coming back and facing rehabilitation since then. I am so
    happy that you are here today and that you continue to serve your
    Nation and my State of Illinois. I could not agree with you more on the
    basic premise that if we cannot provide the medical care promised to
    Steven McCarty and every other soldier, regardless of the war they
    served in or the time that they served, then we need to consider
    alternatives. And I have seen it repeatedly. This morning, as I came in
    here, I met Eric Edmondson on the sidewalk, a man that you know, Tammy,
    and I know well. It is a long and heroic story of his family fighting
    for his rights. This man, a victim of Traumatic Brain Injury in Iraq,
    has made dramatic strides because of the determination of his family.
        When I think of what he went through and I hear Lance Corporal
    McCarty talk about waiting a year--a year?--to have his disability
    claim processed. What is wrong with this picture? We are telling
    recruits if you will show up in 6 weeks we will give you more money to
    go overseas. And now we tell them when they return wounded, wait a year
    before we can tell you what your Government is going to provide? This
    is totally unfair, and something has to be done about it.
        Mr. Williamson, you heard some of the questions earlier that were
    asked about this situation between Massachusetts and the Marion VA, and
    from what we gathered, Massachusetts really did not want to tell the
    Marion VA much about this Dr. Mendez and his giving up his right to
    practice medicine in Massachusetts. During the course of your GAO
    investigation, did you come across anything like this?
        Mr. WILLIAMSON. No, we did not, Senator. We looked at a sample of
    cases at each of the seven facilities we visited and we did not come
    across anything like this.
        Senator DURBIN. It seems to me to make a mockery of recredentialing
    if the individual veterans facility cannot get straight and complete
    answers about the status of licensure of one of their medical staff.
    How could you possibly know whether that person should continue
    practicing? Did you make any recommendations about that in terms of
    your VA study?
        Mr. WILLIAMSON. Well, our recommendations dealt with privileging,
    and really, I think from what I have heard today, that was what VA is
    focusing on. The credentialing process for the seven hospitals that we
    looked at, was following VA requirements. However, privileging, was an
    area we found that needed some improvements. We have not compared VA's
    credentialing and privileging process with that of the private sector.
    VA's got a good system. But the system is only as good as the people
    implementing it, and I really want to say that I think it is important
    to wait for the VA IG's report to come out to see whether it was the
    process or was it the implementation of that process.
        Senator DURBIN. I completely agree with you on that. But I tell
    you, one thing that came out today is the fact that of the 34,000
    medical professionals who are being reviewed--I think that number is
    correct--some 17,000 of them are requiring some follow-up, additional
    information, which is an indication to me that the system
    needs to be a lot more thorough and a lot more complete than it
    currently is. And I think your GAO study may have pointed some
    new directions for us to move in that regard.
        Mr. Chairman, I am going to have to leave for the Judiciary
    Committee. I want to thank this panel. Steven, thank you and your
    family for the sacrifice you made to be here. And, Tammy, I am looking
    forward to continuing to work with you in Illinois and beyond.
    Mr. Williamson, thank you for your insight on this.
        I hope, Mr. Chairman, when this investigation is completed at
    Marion, that we might schedule another hearing to see what lessons can
    be learned. Thank you very much.
        Senator AKAKA. Thank you very much, Senator Durbin. We will look
    very closely at the results of the IG investigation. Thanks so much.
        Mr. McCarty, again, I appreciate your coming forward as you have,
    and I want you to know how sorry we are about what happened to you. I
    hope that your claim for VA benefits will be resolved quickly. Please
    let me know if I can be of assistance in helping to resolve this
    effort.
        At this time I just want to ask whether you have any other
    comments, besides the testimony you have made concerning your
    experiences, and especially what you hope for--what the VA can possibly
    do for you.
        Mr. MCCARTY. At this time, Mr. Chairman, I want to thank you again
    for the opportunity to speak today. The only thing that I can see that
    I would like to come out of this is the doctors at the VA are held
    accountable for their performance. That is really the only thing that I
    would like to be done.
        Senator AKAKA. Well, thank you for that. You know that the focus in
    this hearing has been to that end--to be sure that we can continue
    quality control.
        Ms. Duckworth, talking about quality control--and as I mentioned,
    this is part of the reason for this hearing--what type of quality
    assurance does your office do working in conjunction with the Division
    of Professional Regulation to ensure that veterans in your State
    receive the highest standard of care?
        Ms. DUCKWORTH. Well, sir, we have no say over the Federal VA
    facilities, in our case Hines, Marion, and Danville. All we can do is,
    as we get complaints into our office, refer them to the local hospital
    administrator and bring it to their attention. So, we actually--as a
    State agency--have no say over the Federal.
        We are, however, as a State agency, inspected by the Federal VA as
    well as the State of Illinois Department of Public Health. So our four
    veterans' homes that we operate in the State of Illinois are double
    inspected, not only by the Federal VA when they come out and inspect
    our facilities, but also by our sister agency. And I think that double
    inspection process, while it can be onerous at times, it helps us to
    have a checks and balance as to the entire process. And oftentimes we
    have found that our sister agency is much tougher on us in terms of
    their findings than the Federal VA has been.
        I do want to say, sir, that I have had personally wonderful
    treatment through the VA system. I think that Hines VA, with its blind
    rehabilitation program, with its spinal cord injury program, really
    leads the Nation and that the VA has great expertise that we need to
    respect and maximize. However, I do think that there is opportunity
    here for us to look at some outside care and more participation of
    local communities, teaching hospitals, that sort of thing, to not
    supplant, but supplement the Federal VA. And I think that bringing in
    some outside�as I mentioned earlier, requiring doctors to have
    privileges at the local hospital where the VA hospital is also
    co-located--will help with that process.
        So, as far as the State of Illinois is concerned, we are
    co-inspected by our sister agency in the State of Illinois. We are also
    inspected federally. We have no say whatsoever over the Federal VA
    other than getting complaints and letters and trying to advocate for
    our veterans the best that we can.
        Senator AKAKA. Speaking about Marion, when was your office told by
    VA about the spike in deaths at Marion?
        Ms. DUCKWORTH. I have never received official notice from the
    Federal VA, sir. We have a veterans' home in Anna, in far southern
    Illinois, which sends its patients to Marion VA. The only notice we
    received was that we could no longer send our patients there for
    surgeries, and we have never been informed as to what the reason was
    other than just through the media and me making some phone calls.
        Senator AKAKA. I want to thank you for your remarks about VA
    having the best kind of providers.
        Ms. DUCKWORTH. Yes, sir.
        Senator AKAKA. Unfortunately, you know, there are many clinics,
    many hospitals, and our effort here is to try to maintain quality
    control throughout the system. And your testimony and your responses
    will help us do that, and I am sure will help the administration do it
    as well. We are looking forward to continuing this until the
    investigation is done.
        Mr. Williamson, as may have been the situation in the case of the
    surgeon at Marion, timing clearly poses a problem in the process of
    background checks. Because medical administrators cannot discuss open
    disciplinary investigations, employers may not be aware of serious
    issues surrounding potential hires. My question to you is: How can the
    background-checking process be improved to avoid this problem?
        Mr. WILLIAMSON. Well, as you may know, Mr. Chairman, we did
    work in 2004 and 2006 on screening of all health care practitioners in
    VA. We took issue with the background processes in the sense
    that in many cases they were not being done, and there was not
    adequate documentation to show, in some cases, that the results of the
    background investigation had been reviewed.
        Since that time, VA has implemented some stricter
    background-checking procedures; whereby, they are now doing background
    checks on all their health care providers, and they now have a process
    in place to document that. So, I think with the fingerprint-only kinds
    of background checks that are going on, I think VA is now doing those
    kind of things that we took issue with in earlier work.
        Senator AKAKA. Mr. Williamson, what can be done to lessen the
    chances that Marion will be repeated?
        Mr. WILLIAMSON. I am going to go back to what I said a minute ago,
    Mr. Chairman, and that is that the process can be a good one, but it
    really needs to be followed. And I really cannot comment on the Marion
    situation. I just do not know the facts and, pending the VA IG review,
    I think it would be remiss if I commented on that.
        But I can tell you that I have worked for GAO for over 40 years,
    and in that time I have looked at hundreds--done hundreds and hundreds
    of audits, many of those something like this, where something has gone
    wrong. And in a general sense, without reflecting on Marion, I can tell
    you that there are always--almost always--danger signals that if in
    20/20 hindsight people would have paid attention to, we could have
    prevented these kind of things.
        So I would be, I think, as curious as this Committee is in terms of
    trying to find out what the causes of the Marion situation were.
        Senator AKAKA. Yes. It is interesting. When you raise ``dangerous
    signals,'' it is something that I hope we can deal with, because it is
    important and it is the beginning of something that we need to know
    more about. And with your 40 years of experience with GAO, I hope you
    can come up with a solution to that, so that we can do it here in our
    Government.
        But all of this, of course, would be done for the purpose of
    keeping quality control throughout our system. As was mentioned, when
    you talk about 56,000 doctors, it is huge; and to keep control over the
    56,000 is very difficult. But we have to do that, try our best to do
    that, and this is our effort today.
        So thank you so much, all of you, for your testimonies and for your
    responses, and I want to wish you well. Remember, we are here to
    maintain that high quality of service to our veterans, and that is what
    we are doing.
        Thank you very much, and this hearing is adjourned.
        [Whereupon, at 11:10 a.m., the Committee was adjourned.]

                                     APPENDIX

        PREPARED STATEMENT OF THE AMERICAN ACADEMY OF PHYSICIAN ASSISTANTS

        On behalf of the nearly 65,000 clinically practicing physician
    assistants (PAs) inthe United States, the American Academy of Physician
    Assistants (AAPA) is pleased to submit comments for the hearing record
    on Hiring Practices and Quality Control in VA Medical Facilities. The
    Academy's comments will focus on H.R. 2790, a bill introduced in the
    House by Representatives Phil Hare and Jerry Moran to amend title 38,
    United States Code, to establish the position of Director of Physician
    Assistant Services within the office of the Under Secretary of
    Veterans' Affairs for Health. AAPA believes that enactment of H.R. 2790
    is essential to improving patient care for our Nation's Veterans,
    ensuring that the 1,600 PAs employed by the VA are fully utilized and
    removing unnecessary restrictions on the ability of PAs to provide
    medical care in VA facilities. The Academy believes that enactment of
    H.R. 2790 is necessary to advance recruitment and retention of PAs
    within the Department of Veterans' Affairs and requests that the Senate
    Committee on Veterans' Affairs supports this important legislation.

        Physician assistants are licensed health professionals, or in the
    case of those employed by the Federal Government, credentialed health
    professionals, who--

        practice medicine as a team with their supervising
    physicians
        exercise autonomy in medical decisionmaking
        provide a comprehensive range of diagnostic and therapeutic
    services, including
    performing physical exams, taking patient histories, ordering and
    interpreting laboratory tests, diagnosing and treating illnesses,
    suturing lacerations, assisting in surgery, writing prescriptions, and
    providing patient education and counseling
       may also work in educational, research, and administrative
    settings.

    Physician assistants' educational preparation is based on the medical
    model. PAs practice medicine as delegated by and with the supervision
    of a physician. Physicians may delegate to PAs those medical duties
    that are within the physician�s scope of practice and the PA�s training
    and experience, and are allowed by law. A physician assistant provides
    health care services that were traditionally only performed by a
    physician. All states, the District of Columbia, and Guam authorize
    physicians to delegate prescriptive privileges to the PAs they
    supervise. AAPA estimates that in 2006, approximately 231 million
    patient visits were made to PAs and approximately 286 million
    medications were prescribed or recommended by PAs.
        The PA profession has a unique relationship with veterans. The
    first physician assistants to graduate from PA educational programs
    were veterans--former medical corpsmen who had served in Vietnam and
    wanted to use their medical knowledge and experience in civilian life.
    Dr. Eugene Stead of the Duke University Medical Center in North
    Carolina put together the first class of PAs in 1965, selecting Navy
    corpsmen who had considerable medical training during their military
    experience as his students. Dr. Stead based the curriculum of the PA
    program in part on his knowledge of the fast-track training of doctors
    during World War II. Today, there are 139 accredited PA educational
    programs across the United States. Approximately 1,600 PAs are employed
    by the Department of Veterans Affairs, making the VA the largest single
    employer of physician assistants. These PAs work in a wide variety of
    medical centers and outpatient clinics, providing medical care to
    thousands of veterans each year. Many are veterans themselves.
        Physician assistants are fully integrated into the health care
    systems of the Armed Services and virtually all other public and
    private health care systems. PAs are on the front line in Iraq and
    Afghanistan, providing immediate medical care for wounded men and women
    of the Armed Forces. Within each branch of the Armed Services, a Chief
    Consultant for PAs is assigned to the Surgeon General. PAs are covered
    providers in TRICARE. In the civilian world, PAs work in virtually
    every area of medicine and surgery and are covered providers within the
    overwhelming majority of public and private health insurance plans. PAs
    play a key role in providing medical care in medically underserved
    communities. In some rural communities, a PA is the only health care
    professional available.
        AAPA is very appreciative of the leadership of many Members of the
    Senate Committee on Veterans' Affairs in creating the VA's Physician
    Assistant (PA) Advisor to the Under Secretary for Health. The current
    PA Advisor to the Under Secretary for Health was authorized through
    section 206 of P.L. 106-419 and has been filled as a part-time, field
    position. Prior to that time, the VA had never had a representative
    within the Veterans Health Administration with sufficient knowledge of
    the PA profession to advise the Administration on the optimal
    utilization of PAs. This lack of knowledge resulted in an inconsistent
    approach toward PA practice, unnecessary restrictions on the ability of
    VA physicians to effectively utilize PAs, and an under-utilization of PA skills and abilities. The PA profession�s scope of practice was not
    uniformly understood in all VA medical facilities and clinics, and
    unnecessary confusion existed regarding such issues as privileging,
    supervision, and physician countersignature.
        Although the PAs who have served as the VA's part-time, field-based
    PA Advisor have made progress on the utilization of PAs within the
    agency, there continues to be inconsistency in the way that local
    medical facilities use PAs. In one case, a local facility decided that
    a PA could not write outpatient prescriptions, despite licensure in the
    state allowing prescriptive authority. In other facilities, PAs are
    told that the VA facility can not use PAs and will not hire PAs. These
    restrictions hinder PA employment within the VA, as well as deprive
    veterans of the skills and medical care PAs have to offer.
        The AAPA believes that a full-time Director of PA Services within
    the VA Central Office is necessary to recruit and retain PAs in the
    Department of Veterans' Affairs. PAs are in high demand in the private
    market place.

        The US Bureau of Labor Statistics (BLS) projects that the
    number of PA jobs will increase by 50 percent between 2004 and 2014 and
    has ranked the profession as the fourth fastest growing profession in
    the country.
        US News and World Report named the PA profession within its
    2007 list of 25 best careers.
         Money magazine ranked the PA profession No. 5 in its 2006
    list of top careers; CNN listed the PA profession as No. 4 in its 2006
    list of top US careers.

        The growth in PA jobs is in the private sector, not the Federal
    Government. AAPA believes that the Federal Government, including the
    Department of Veterans' Affairs, will not be able to compete with the
    private market unless special efforts are made to recruit and retain
    PAs.  According to the AAPA�s 2006 Census Report, an estimated 3,545
    PAs are employed by the Federal Government to provide medical care.
    Unfortunately, AAPA�s Annual Census Reports of the PA Profession from
    1997 to 2006 document an overall decline in the number of PAs who
    report Federal Government employment. In 1991, nearly 13.4 percent of
    the total profession was employed by the Federal Government. This
    percentage dropped to 6 percent in 2006.

        The Academy also believes that the elevation of the PA Advisor to a
    full-time Director of Physician Assistant Services, located in the VA
    central office, is necessary to increase veterans' access to quality
    medical care by ensuring efficient utilization of the VA's PA workforce
    in the Veterans Health Administration�s patient care programs and
    initiatives. PAs are key members of the Armed Services' medical teams
    but are an underutilized resource in the transition from active duty to
     veterans' health care. As health care professionals with a
    longstanding history of providing care in medically underserved
    communities, PAs may also provide an invaluable link in enabling
    veterans who live in underserved communities to receive timely access
    to quality medical care.

        Thank you for the opportunity to submit a statement for the hearing
    record in support of legislation to elevate the VA's PA Advisor to a
    full-time position in the VA's central office. AAPA is eager to work
    with the Senate Committee on Veterans' Affairs to improve the
    availability and quality of medical care to our Nation�s veteran
    population.