[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 Generalï¿½s 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 appreciateï¿½is 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 todayï¿½s 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 beï¿½into 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 causeï¿½that is, for reasons 
of substandard care, professional misconduct, or professional incompetenceï¿½that 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 Divisionï¿½s 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 Divisionï¿½s 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 providerï¿½s 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 pastï¿½voluntary 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 inspectorï¿½s 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 statisticalï¿½it 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 practitionerï¿½to 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, Senatorï¿½and 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 physiciansï¿½ 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 Iï¿½ve 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 Nationï¿½s 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 outsideï¿½as 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 physicianï¿½s scope of practice and the PAï¿½s 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 professionï¿½s 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 AAPAï¿½s 2006 Census Report, an estimated 3,545 
PAs are employed by the Federal Government to provide medical care. 
Unfortunately, AAPAï¿½s 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 Administrationï¿½s 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 Nationï¿½s veteran 
population. 




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