[House Hearing, 113 Congress]
[From the U.S. Government Publishing Office]



 
          VA ACCOUNTABILITY: ASSESSING ACTIONS TAKEN 
            IN RESPONSE TO SUBCOMMITTEE OVERSIGHT

=======================================================================

                                HEARING

                               BEFORE THE


                         SUBCOMMITTEE ON HEALTH

                                 OF THE
                                 
                     COMMITTEE ON VETERANS' AFFAIRS
                     U.S. HOUSE OF REPRESENTATIVES

                    ONE HUNDRED THIRTEENTH CONGRESS

                             SECOND SESSION

                               __________

                      WEDNESDAY, FEBRUARY 26, 2014

                               __________

                           Serial No. 113-54

                               __________

       Printed for the use of the Committee on Veterans' Affairs
       
       
       
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                     COMMITTEE ON VETERANS' AFFAIRS

                     JEFF MILLER, Florida, Chairman

DOUG LAMBORN, Colorado               MICHAEL H. MICHAUD, Maine, Ranking 
GUS M. BILIRAKIS, Florida, Vice-         Minority Member
    Chairman                         CORRINE BROWN, Florida
DAVID P. ROE, Tennessee              MARK TAKANO, California
JEFF DENHAM, California              JULIA BROWNLEY, California
BILL FLORES, Texas                   DINA TITUS, Nevada
JON RUNYAN, New Jersey               ANN KIRKPATRICK, Arizona
DAN BENISHEK, Michigan               RAUL RUIZ, California
TIM HUELSKAMP, Kansas                GLORIA NEGRETE McLEOD, California
MIKE COFFMAN, Colorado               ANN M. KUSTER, New Hampshire
BRAD R. WENSTRUP, Ohio               BETO O'ROURKE, Texas
PAUL COOK, California                TIMOTHY J. WALZ, Minnesota
JACKIE WALORSKI, Indiana
DAVID JOLLY, Florida
                       Jon Towers, Staff Director
                 Nancy Dolan, Democratic Staff Director

                         SUBCOMMITTEE ON HEALTH

                    DAN BENISHEK, Michigan, Chairman

DAVID P. ROE, Tennessee              JULIA BROWNLEY, California, 
JEFF DENHAM, California                  Ranking Minority Member
TIM HUELSKAMP, Kansas                CORRINE BROWN, Florida
JACKIE WALORSKI, Indiana             RAUL RUIZ, California
BRAD R. WENSTRUP, Ohio               GLORIA NEGRETE McLEOD, California
                                     ANN M. KUSTER, New Hampshire

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public 
hearing records of the Committee on Veterans' Affairs are also 
published in electronic form. The printed hearing record remains the 
official version. Because electronic submissions are used to prepare 
both printed and electronic versions of the hearing record, the process 
of converting between various electronic formats may introduce 
unintentional errors or omissions. Such occurrences are inherent in the 
current publication process and should diminish as the process is 
further refined.
                            C O N T E N T S

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                                                                   Page

                      Wednesday, February 26, 2014

VA Accountability: Assessing Actions Taken In Response To 
  Subcommittee Oversight.........................................     1

                           OPENING STATEMENTS

Hon. Dan Benishek, Chairman......................................     1
    Prepared Statement...........................................    31
Hon. Julia Brownley, Ranking Member..............................     3
    Prepared Statement...........................................    32

                                WITNESS

Hon. Robert Petzel, M.D., Under Secretary for Health, Veterans 
  Health Administration, U.S. Department of Veterans' Affairs....     5
    Prepared Statement...........................................    33

    Accompanied by:

        Robert Jesse, M.D., Principal Deputy Under Secretary for 
            Health VHA, U.S. Department of Veterans Affairs

        Madhulika Agarwal, M.D., M.P.H., Deputy Under Secretary 
            for Health for Policy and Services, Veterans Health 
            Administration, U.S. Department of Veterans Affairs

        Rajiv Jain M.D., Assistant Deputy Under Secretary for 
            Patient Care Services, VHA, U.S. Department of 
            Veterans Affairs

    And

        Phillip Matkovsky, Assistant Deputy Under Secretary for 
            Health for Administrative Operations, VHA, U.S. 
            Department of Veterans Affairs

                   MATERIAL SUBMITTED FOR THE RECORD

Letter and Questions From: Hon. Dan Ben to Hon. Robert A. Petzel.    39
Questions From: Hon. Dan Benishek and Responses From: VA.........    42
Letter From: Hon. Robert A. Petzel to Hon. Dan Benishek..........    73
Deliverables From: VA............................................    73


VA ACCOUNTABILITY: ASSESSING ACTIONS TAKEN IN RESPONSE TO SUBCOMMITTEE 
                               OVERSIGHT

                      Wednesday, February 26, 2014

             U.S. House of Representatives,
                    Committee on Veterans' Affairs,
                            Subcommittee on Health,
                                                   Washington, D.C.
    The subcommittee met, pursuant to notice, at 10:04 a.m., in 
Room 334, Cannon House Office Building, Hon. Dan Benishek 
[chairman of the subcommittee] presiding.
    Present:  Representatives Benishek, Huelskamp, Wenstrup, 
Brownley, Ruiz, Negrete-McLeod, and Kuster.

          OPENING STATEMENT OF DAN BENISHEK, CHAIRMAN

    Dr. Benishek. Good morning. The subcommittee will come to 
order.
    Thank you for joining us today for the oversight hearing VA 
Accountability: Actions Taken in Response to Subcommittee 
Oversight.
    Almost one year ago today during my first hearing as 
chairman of the Subcommittee on Health, we met to discuss the 
persistent lack of productivity and staffing standards for 
specialty care services at Department of Veterans Affairs' 
medical facilities.
    We learned that VA had yet to implement these standards 
despite more than 30 years of reports and recommendations 
directing the department to do so.
    I was so alarmed by VA's decades long lack of action that I 
quickly introduced H.R. 2072, the Demanding Accountability for 
Veterans Act. H.R. 2072 would require VA to ensure that 
inspector general recommendations concerning a public health or 
patient safety issue were addressed, identify those within VA 
medical facilities who are responsible for implementing needed 
changes, and prohibit the VA from awarding a bonus or 
performance award to any employee who does not fully address a 
recommendation under his or her purview.
    The goal of this legislation is to create a culture of 
accountability within VA, a culture where problems are 
identified and immediately corrected and leaders are held 
responsible for their actions.
    Were H.R. 2072 in place 30 years ago, VA would have been 
required long before now to implement productivity and staffing 
standards for all specialty care services and who knows how the 
health and well-being of a veteran seeking care through VA 
would have improved as a result.
    I wish I could say that the first hearing was the only time 
that we have seen evidence of a lack of timely action taken by 
VA in response to serious problems. Unfortunately, that is not 
true.
    Since the conclusion of that hearing, we have held other 
hearings and roundtables on topics ranging from the care 
provided to veterans with chronic pain and who have experienced 
military sexual trauma to concerns regarding department-wide 
procurement reform and third-party collections.
    At each of these oversight forums, we have heard example 
after example of VA failing to act swiftly to address important 
issues or respond to the subcommittee's requests for 
information in a timely manner.
    I am a surgeon. When a serious problem is identified, my 
instinct is to act without delay, to cut out what needs cutting 
out, and to fix what needs fixing.
    While I understand that large-scale changes often happen 
slowly, especially where large government bureaucracies like VA 
are concerned, I think we can all agree that our veterans 
deserve more than what we have seen in the last year.
    I am hopeful that H.R. 2072 will be heard on the House 
floor in the coming weeks. However, I am not content to wait 
for what can often be a lengthy legislative process to ensure 
that VA is on track to address the many issues the subcommittee 
has identified through last year's oversight efforts.
    During today's hearing, we will assess the progress, if 
any, that VA has made in response to the subcommittee's 
hearings and roundtables, determine whether appropriate steps 
have been taken to ensure accountability when and where 
deficiencies in care have been highlighted, and identify what 
further actions may be necessary to improve the care and 
services provided to our veterans.
    Though the topics we address today are wide ranging, they 
are undoubtedly interconnected. If we do not ensure the 
department is on track to implement appropriate productivity 
and staffing standards, then we cannot be sure that we have the 
right staff in place to care for veterans experiencing chronic 
pain.
    Similarly, if we do not ensure that the VA is taking 
necessary actions to improve the collection where appropriate 
of third-party revenue, then we cannot be sure that we are 
collecting every available dollar that could be used to improve 
the care and services provided to veteran survivors of military 
sexual trauma.
    Last week, I had the privilege of conducting an oversight 
visit to the West LA VA Medical Center. During my conversations 
with the clinicians and support staff there, each of the issues 
we will discuss today were brought up by the providers when I 
asked them what needed to be improved in order to make it 
easier for them to care for our veterans.
    I cannot state enough how critical it is for VA to take 
responsibility for gaps in care and, more importantly, to take 
immediate and definitive steps to address them.
    Unfortunately, I have seen little concrete evidence in the 
past year that the department is doing either. Concurring with 
IG and GAO reports is simply not enough. Sending out guidelines 
without accountability is not enough. I sincerely hope that 
today's conversation will change my mind.

    [The prepared statement Hon. Dan Benishek appears in the 
Appendix]

    With that, I will recognize Ranking Member Brownley for any 
opening statement she may have.

      OPENING STATEMENT OF JULIA BROWNLEY, RANKING MEMBER

    Ms. Brownley. Thank you, Mr. Chairman, and good morning.
    Today's hearing is intended to follow-up on various 
oversight hearings and roundtables held during the first 
session of the 113th Congress and to assess the progress that 
the department has made in addressing these critical issues.
    The subcommittee will also determine whether appropriate 
steps have been taken by the VA to ensure accountability and 
identify what further actions may be necessary in response to 
subcommittee oversight.
    Last session, this subcommittee held oversight hearings on 
physician staffing standards, care and treatment for military 
sexual trauma survivors, and VA's overuse of prescription 
painkillers to treat veterans with chronic pain.
    In addition to the oversight hearings, two roundtables were 
held, one focusing on procurement reform and access to care and 
one on billing and collecting from third-party health insurance 
companies for nonservice-connected care.
    There were many issues raised during these hearings and 
roundtables, issues such as developing a plan to establish 
productivity standards for all specialty care services within 
three years, decreasing the amount of time it takes to procure 
large medical equipment through the national acquisition 
center, assessing the department's programs for veterans who 
have experienced military sexual trauma, and ensuring the 
effective use of opiate therapy for patients with chronic pain.
    Mr. Chairman, these are but a few of the concerns that were 
brought up during testimony and conversations we had with the 
witnesses and participants during these forums. While we have a 
lot of ground to cover today, I am especially interested in 
hearing from the VA on improvements made in the military sexual 
trauma program and in procurement reform.
    At the MST hearing held last session, we heard firsthand 
the experiences of veterans who have found the system 
unfriendly and intimidating.
    According to the VA, fiscal year 2013 saw an increase of 
9.3 percent in rates of engagement of military sexual trauma 
related care at VHA. Additionally, the VA reports an increase 
of 14.6 percent in military sexual trauma related visits in 
fiscal year 2013.
    I would like to hear from the VA how they are addressing 
these increases. I am sure we all agree that it is critical 
that Congress do all that we can to make it easier for victims 
of military sexual trauma to access needed benefits and 
services and receive treatment. Compassion and care are a 
significant part of healing those that have been sexually 
assaulted.
    Turning now to procurement reform, Mr. Chairman, last 
session, we held a roundtable and during that roundtable 
discussion, we heard about the long delays, some for up to two 
years, in the delivery of medical equipment.
    While I understand that VA is streamlining the procurement 
process to decrease the amount of time it takes to procure 
large medical equipment through the national acquisition 
center, I do not feel confident that much progress has been 
made in that area.
    Stakeholders continue to report increased difficulties 
accessing needed prosthetic equipment through VA and 
significant delays in contract awards at the national 
acquisition center. I find this very frustrating and 
unnecessary. I hope the VA has good news on this front today.
    Mr. Chairman, thank you for holding this hearing today, and 
I want to thank everyone in attendance. There is obvious 
concern for veterans and VA's ability to meet their healthcare 
needs.
    Thank you, Mr. Chairman, and I yield back the balance of my 
time.

 [The prepared statement of Hon. Julia Brownley appears in the 
                           Appendix]

    Dr. Benishek. Thank you, Ms. Brownley.
    With that, I will introduce our first and only witness 
panel. Representing the department is the Honorable Under 
Secretary for Health, Dr. Robert Petzel.
    Dr. Petzel is accompanied by Dr. Jesse, the principal 
deputy under secretary for Health; Dr. Agarwal, the deputy 
under secretary for Health for Policy and Services; Dr. Jain, 
the assistant deputy under secretary for Patient Care Services; 
and Mr. Philip Matkovsky, the assistant deputy under secretary 
for Health for Administrative Operations.
    Together each of you represent the lead VA witnesses at the 
three oversight hearings and the two roundtable discussions 
that will be the focus of today's hearing. Thank you all for 
being here today.
    Dr. Petzel, please proceed with your testimony.

    STATEMENT OF ROBERT PETZEL, UNDER SECRETARY FOR HEALTH, 
  VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS 
 AFFAIRS, ACCOMPANIED BY ROBERT JESSE, PRINCIPAL DEPUTY UNDER 
  SECRETARY FOR HEALTH, VETERANS HEALTH ADMINISTRATION, U.S. 
DEPARTMENT OF VETERANS AFFAIRS; MADHULIKA AGARWAL, DEPUTY UNDER 
 SECRETARY FOR HEALTH FOR POLICY AND SERVICES, VETERANS HEALTH 
  ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS; RAJIV 
    JAIN, ASSISTANT DEPUTY UNDER SECRETARY FOR PATIENT CARE 
 SERVICES, VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF 
  VETERANS AFFAIRS; PHILIP MATKOVSKY, ASSISTANT DEPUTY UNDER 
 SECRETARY FOR HEALTH FOR ADMINISTRATIVE OPERATIONS, VETERANS 
   HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS

                   STATEMENT OF ROBERT PETZEL

    Dr. Petzel. Good morning, Chairman Benishek and Ranking 
Member Brownley and Members of the committee. Thank you for the 
opportunity to discuss the progress that we have made regarding 
Veterans Health Administration's physician staffing, 
productivity standards, treatment for veterans who experience 
military sexual trauma, pain management, and procurement 
reform.
    The chairman has already mentioned the people that are 
accompanying me.
    The Veterans Health Administration is the largest 
integrated healthcare delivery system in the country providing 
85 million total healthcare appointments and last year, we had 
25 million consultation requests. And we deliver this care at 
1,700 VA healthcare sites.
    I want to address first the issue of accountability. 
Allegations of misconduct by employees are taken seriously by 
VA. When we learn of credible allegations of misconduct, VA 
addresses them immediately. When incidents occur, we identify, 
mitigate, and prevent additional risks.
    Prompt reviews prevent similar events in the future and 
hold those responsible accountable. If an employee misconduct 
or failure to meet performance is identified, VA does take 
appropriate action.
    Effectively treating veterans who experience military 
sexual trauma continues to be a top priority for VA. We are 
committed to ensuring that appropriate MST services are 
available to meet the treatment needs of both men and women.
    Since last year's hearing on military sexual trauma, VA has 
taken a number of steps that have resulted in improvements. VA 
is in the process of administrating and implementing an 
enhanced universal MST screening to include a clinical reminder 
for referrals. We are providing military sexual trauma 
telemental health for rural veterans and recently we 
distributed to all affected employees an information bulletin 
on managing military sexual trauma.
    A number of roundtables were hosted to examine the impact 
of department-wide acquisition reform. Since that roundtable 
discussion, the department has expanded its use of authorities 
to acquire care from community healthcare providers, 
successfully launching the patient centered care in the 
community or PC3. VA has completed its consolidation of billing 
through the consolidated patient account centers. And, 
additionally, we have welcomed the oversight from the Health 
Subcommittee during our roundtables. We have used this 
oversight process to inform continued improvements in our 
administrative processes which we will illuminate during the 
hearing.
    Last year, we also participated in a hearing regarding VA 
productivity and staffing. Today I am pleased to report that by 
the end of March 2014, we will have productivity and staffing 
standards in place for 25 different specialties representing 81 
percent of our total physician workforce. And we are on target 
to deliver productivity and staffing standards for all VA 
physicians by the end of fiscal year 2014.
    In October of 2013, VA briefed the OIG on its progress. 
Based on VA's briefing, the OIG has closed out all of its 
recommendations related to physician staffing. The work 
continues and will not be finished until all physician 
specialty productivity and staffing standards are complete, 
implemented, and ready access to high-quality, efficient 
specialty care is available to all of our Nation's veterans.
    Lastly, VA is providing comprehensive pain management 
services to improve the health of veterans. As an update to 
last year's pain management hearing, VA recently developed and 
implemented an opioid safety initiative program to ensure 
opioid medications are used safely, effectively, and 
judiciously.
    The program is already bringing positive results. The basis 
for this program is to make visible the totality of opioid use 
at all levels, patient, provider, and facility, in order to 
identify high-risk situations.
    To support a system-wide approach, VA disseminated guidance 
and tools to help providers to communicate long-term opioid 
therapy expectations to the staff and to their patients.
    In addition, a multi-module, team-based, stepped-care model 
has been implemented throughout VA. Every VA medical center has 
a pain clinic and a consultation service for pain and opioid 
monitoring and provider feedback program and the capacity to 
provide interdisciplinary treatment such as physical therapy, 
behavioral therapy, non-opioid medications, and alternative 
medical care such as acupuncture and meditation.
    VA prescribers also have the ability to participate in the 
state prescription drug monitoring program to determine if a 
patient of theirs is receiving controlled substance 
prescriptions from non-VA sources.
    Mr. Chairman, the Department of Veterans Affairs is 
committed to providing the highest quality of care that our 
veterans have earned and that they deserve.
    As mentioned earlier, important progress has been made 
regarding these programs. We at VA will continue to identify, 
mitigate, and prevent vulnerabilities within our healthcare 
system wherever we find them. VA will continue to ensure 
accountability and when adverse events do occur, we will learn 
from them, improve our system to prevent these incidents from 
happening again.
    This concludes my testimony. I appreciate the 
subcommittee's continued interest in the health and the welfare 
of America's veterans. And at this time, my colleagues and I 
are prepared to answer your questions.

    [The prepared statement of Robert Petzel appears in the 
                           Appendix]

    Dr. Benishek. Thank you, Dr. Petzel. I appreciate your 
response.
    I expect we will have multiple rounds of questions today, 
and I will begin by yielding myself five minutes.
    While the purpose of this hearing is to go over, the issues 
that we raised over the past year in the hearings and 
roundtables that we have done, I just want to ask a few 
questions about your statement.
    Specifically you said allegations of misconduct by 
employees are taken seriously. When we learn of credible 
allegations of misconduct, VA addresses them immediately.
    So within the past year, the committee has examined, you 
know, disturbing lapses of leadership including, several 
incidents around VA like at the Pittsburgh VA Medical Center 
where several veterans succumbed to Legionnaires' disease.
    There was apparently some improper emergency room care that 
led to three preventable patient deaths at the Memphis VA 
according to the VA inspector general's report and recently 19 
preventable deaths were reported nationwide including six 
deaths at the Columbia, South Carolina VAMC and three deaths at 
the Augusta, Georgia VAMC due to avoidable delays in care.
    So were these instances I just reported to you, were they 
considered credible allegations of misconduct?
    Dr. Petzel. Yes, Mr. Chairman, they were.
    Dr. Benishek. So then what specific actions were taken 
immediately upon your being aware of these?
    Dr. Petzel. Let's go back and go through each one of them 
individually. At Memphis, two physicians have been disciplined. 
One has been removed as a result of the actions in Memphis. At 
Columbia, three senior executives have resigned under threat of 
discipline.
    And at Pittsburgh, as you may remember, there was a 
criminal investigation done by our criminal IG and by the 
Department of Justice. When they finished, they found that 
there was no criminal activity. In fact, they found that only 
one of those six patients had actually died from legionella and 
the others died from other illnesses.
    At any rate, we were forbidden from doing any further 
investigation or taking any action until after those 
investigations were finished. They finished and we're now in 
the process of evaluating disciplinary action for people at 
Pittsburgh.
    Dr. Benishek. There was some other references to 
mismanagement not linked to deaths or discipline described as 
temporary written warnings.
    Tell me more about that. it seems inadequate, that 
mismanagement was not linked to deaths. What is the appropriate 
action for that type of behavior?
    Dr. Petzel. That is in my mind a hypothetical question. It 
depends on what has happened. The range of discipline that can 
be incurred is anywhere from an admonishment to removal. I 
would point out that last year, VA removed 3,000 employees, 
approximately one percent of its workforce.
    They over the last two years have either removed or seen 
resignations on threat of discipline from 14 senior executives 
and an additional number of senior executives on probationary 
periods were fired during their probationary period.
    So, sir, we do discipline our workforce. We do hold our 
workforce accountable.
    Dr. Benishek. It is amazing when I keep hearing this, but 
the specific instances seem to me to be a little bit more 
difficult. I am happy to hear what you have to say about those 
particular cases, but it seems from, you know, my experience 
that finding the person responsible, seems to be difficult as 
we talked about in the, physician staffing hearings that we 
had.
    Dr. Petzel. Let me just make just a couple more comments if 
I could, Mr. Chairman.
    We have got a pretty extensive oversight system that 
includes the activities of this committee, the special counsel, 
the Office of the Inspector General, the GAO, and the Office of 
the Medical Inspector. These all help us determine whether or 
not people were accountable for the action.
    The IG investigated Pittsburgh as an example and did not 
find that there was any individual----
    Dr. Benishek. Well----
    Dr. Petzel [continuing]. They felt was----
    Dr. Benishek. Right. Well, you know, my best example of 
that to tell you the truth, Dr. Petzel, is the example of when 
we had at the physician staffing hearing. The IG over the last 
30 years has eight times said that there should be a 
centralized plan for physician staffing and, yet, that 
centralized plan over the last 30 years does not exist.
    When I asked the fellow testifying, he said, ``we will have 
a plan in three years'' and, yet, I could not find out the name 
of the person who was supposed to respond to that inspector 
general report and make that plan happen.
    The IG said you need a central plan. You agreed. Eight 
times over 30 years and, yet, it did not happen. And we could 
not find out who the person who was supposed to be doing that 
is. This is the frustration that I have as chairman.
    I am over time now, but maybe we will get back to that. I 
would like to yield to Ms. Brownley for her five minutes.
    Ms. Brownley. Well, thank you, Mr. Chair. I certainly want 
your question answered.
    And, you know, I wanted to just kind of follow-up as well 
on the productivity standards for specialty physicians, too.
    And if I heard you correctly, Dr. Petzel, you said that all 
will be done by March 2014?
    Dr. Petzel. That is correct, Congressman Brownley.
    Ms. Brownley. Okay. So all of them will be done by 2014. So 
then I have to assume that all of the various milestones and 
both stage one and stage two as was laid out by you to me have 
all been completed then at this particular point in time?
    Dr. Petzel. I would ask Dr. Agarwal to comment on it.
    Dr. Agarwal. So, Ranking Member Brownley, you are correct. 
You know, we had stated in our testimony at that hearing that 
we will complete all specialty physician standards within three 
years. However, we have accelerated that path.
    And at this point as Dr. Petzel mentioned, we have 
completed the standards for 81 percent of our specialties and 
we intend to complete all of them this fiscal year. So, yes, 
ma'am, we----
    Ms. Brownley. Could you give me an idea of what the 
outstanding ones are?
    Dr. Agarwal. Of the specialties?
    Ms. Brownley. Yes.
    Dr. Agarwal. Yes, ma'am. I do have a list with me. If you 
would like me to go through, I will be happy to do so.
    Ms. Brownley. Well, if you could just give me a few off the 
top of your head just to have an idea of what they may be.
    Dr. Agarwal. The ones that are remaining?
    Ms. Brownley. Correct.
    Dr. Agarwal. Okay. So we have for thoracic surgery, 
vascular surgery, cardiology surgery, anesthesia, emergency 
medicine, pathology amongst a few that we still need to 
complete. The ones that we have already completed are as 
follows:
    When I had initially testified, we had the staffing models 
for primary care as well as radiology and mental health was on 
its way. And I am pleased to say that the directive for mental 
health staffing went out a couple of months later after the 
hearing.
    Subsequently the standards that we have placed are for 
dermatology, gastroenterology, neurology, ophthalmology, 
orthopedic surgery, urology, as well as allergy, immunology, 
endocrine, and I have the list with me. So I would be happy to 
share that with you.
    Ms. Brownley. Thank you very much.
    And just again as a follow-up question that once all of 
these are established, then can you explain to me how we will 
then measure sort of the accuracy and the effectiveness of 
these standards for all of the specialties that you have 
developed? So are you creating metrics for us to measure the 
effectiveness and the quality responses?
    Dr. Petzel. I will let Dr. Agarwal give you some details 
about that. But just it is sort of an overview. The staffing 
standards look at the delivery of services within a department, 
say cardiology or ophthalmology, and they also blend with that 
the access that we have to those services. So we look at the 
access standards and we get a picture of the productivity of 
our staffing and the effect that it is having on the ability of 
people to access the care which I think is the ultimate thing 
that we are looking for.
    We want to have enough people to provide good access, not 
so many people that we are not being effective in the way we 
administer that program.
    And Dr. Agarwal might add anything to that.
    Dr. Agarwal. Sure. So subsequent to the hearing, ma'am, we 
have gone ahead and we have developed many tools that will 
assist the local facilities in managing the specialty resources 
appropriately. We would like all our specialists to work at the 
top of their license which entails that they also need to have 
the necessary support staff so that they are able to perform 
their specialist duties in helping veterans.
    And to that end, I will reference back to the tool that Dr. 
Petzel just mentioned. It is an algorithm that links access 
with specialty productivity. All our leadership has been 
trained to use this tool and how they manage the specialty 
resources in the clinics and appointments.
    Ms. Brownley. I think what I am trying to drive at and I 
think it is important for you as the experts to be able to 
evaluate the effectiveness and the quality of delivery of 
services, what kind of tools will Congress have, will the 
veteran community have to also be able to measure the quality 
and effectiveness of these specialties?
    Dr. Agarwal. That is an excellent point, ma'am. So this 
tool has been currently distributed to all our facilities and 
they are using it to manage the resources within their medical 
centers.
    So the ultimate outcome of this is going to be better 
access of specialty services to the veterans as well as our 
ability to use our specialists most efficiently and 
effectively.
    To that end, we would like to share that information with 
Congress as and when you would like to have it. We can do that 
periodically at your request.
    Ms. Brownley. Thank you.
    And, Mr. Chair, I yield back. I exceeded my time.
    Dr. Benishek. Thank you, Ms. Brownley.
    I would like to yield five minutes to Dr. Huelskamp.
    Dr. Huelskamp. Thank you, Mr. Chairman. I appreciate the 
opportunity to follow-up on some issues we have discussed in 
the last year. I appreciate your line of questioning and 
hopefully you will take that up when you return to that.
    But one thing I would like to first ask the VA is in 
reference to a year ago, approximately a year ago during a 
March 6 hearing, I asked the GAO some questions regarding the 
scheduling practices at the VA. During the course of my 
questioning, the GAO noted the dates were changed to game the 
system at several clinics.
    And I believe, Mr. Matkovsky, you were in attendance at the 
hearing and I asked your colleague, Mr. Shonnard, what was 
being done to prevent this from happening again and whether any 
penalties were imposed on the employees caught doing this.
    My question for the VA is this. Who has been held 
accountable for these actions?
    Dr. Petzel. Before I turn to Mr. Matkovsky, Congressman 
Huelskamp, let me answer that.
    The GAO was referring to a system that we used for 
scheduling that we have since abandoned which had in it the 
possibilities of both misunderstanding of what might be 
scheduled and what the times might mean.
    We have moved to having the fundamental scheduling criteria 
be what we call the create date. And that create date is not 
fungible. That is the date that the individual calls into the 
medical center or wherever it might be and asks for an 
appointment. That becomes then the starting point for measuring 
whether or not we have accomplished seeing that patient within 
the 14-day criteria that we set out.
    So that should not occur. I cannot speak to what has 
happened previously. I----
    Dr. Huelskamp. Doctor, so you have abandoned the system 
that allowed and permitted employees to falsify and game the 
system.
    My question is, have you held anybody accountable for the 
actions that were identified by the GAO?
    Dr. Petzel. I would have to go back, sir, and look to see 
if there were any disciplinary actions in those 3,000 that I 
mentioned that were specifically related to that issue. I do 
not know the answer to that question here.
    Dr. Huelskamp. Any of the other conferees, can you answer 
that question, whether anybody was held accountable for gaming 
the system?
    Dr. Jesse. I cannot answer the question directly because 
there are 70 some thousand people who have scheduling keys on 
our system. So I do not know, you know, specifically whom you 
are referring.
    I think the important point is----
    Dr. Huelskamp. Did you follow-up with the GAO? They had 
evidence of that. They had identified specific instances.
    Dr. Jesse. Like I say, I cannot give you the specifics on 
that.
    Dr. Huelskamp. No one here followed up on the GAO? And you 
saw this report yesterday suggesting that is going on elsewhere 
in the system in which the VA purged thousands of medical 
tests, this is just yesterday's article, to game its backlog 
stats.
    So first question, follow-up of the GAO report, it was just 
ignored then?
    Mr. Matkovsky. No, Congressman Huelskamp. I went back and 
asked some of our team to identify, if we could, the 
allegations that were presented by the GAO during that hearing. 
We were not able to find concrete evidence that the GAO had and 
they did not actually give us the specifics so that we could go 
to the individual and find it.
    So we did follow-up. We could not find the concrete 
evidence to engage an appropriate disciplinary action, sir.
    Dr. Huelskamp. So you just abandoned the system and those 
employees that were followed up?
    A little more on the GAO. So the GAO made allegations and 
you never reported back to the committee that I am aware that 
GAO was mistaken or provided no evidence of that. I have 
appreciated the product from the GAO and you are saying here 
they had no evidence of that?
    Mr. Matkovsky. That is not what I am saying. I am saying 
that we did not have independent evidence outside of the GAO 
report that could identify an individual who engaged in the----
    Dr. Huelskamp. Well, where did they come up with that, sir?
    Mr. Matkovsky. They had their evidence.
    Dr. Huelskamp. Their evidence is from your system.
    Mr. Matkovsky. That is correct, sir.
    Dr. Huelskamp. So their evidence was inaccurate?
    Mr. Matkovsky. It was interview based, if you recall, so 
they had a series of clinics that they visited and then they 
went through and monitored the behavior. They measured that 
behavior against the policy and they identified that someone 
instead of selecting the desired date of the veteran, they were 
asking the veteran when they wanted to be seen and using that 
as the desired date.
    So they were monitoring behavior specifically and we were 
attempting to find evidence of that on our own and we could 
not.
    Dr. Huelskamp. And, lastly, any responses to this report 
again of gaming the system that came out yesterday? Apparently 
any request for documents describing when the practice began or 
how many employments have been cancelled was refused.
    Dr. Petzel. That was almost what I would call a scurrilous 
newspaper report. Several years ago, the West LA Greater Los 
Angeles healthcare system embarked on a very carefully thought 
out review of past requests for consultation or x-rays in the 
imaging department to see if indeed there were requests that 
had not yet been closed out.
    They identified 300 requests that had not been closed out. 
They had not been closed out because the patients had moved, 
because the patients had failed to show up for the appointment 
or repeat appointments.
    There was nobody who needed the care that was denied the 
care. There was no attempt to eliminate a backlog by destroying 
records. You cannot destroy the records. They are electronic 
and they are there forever.
    Dr. Huelskamp. But they were administratively closed, is 
that----
    Dr. Petzel. They were administratively closed.
    Dr. Huelskamp. And according to the article, it is not a 
few thousand. It is 40,000 in LA and 13,000 in Dallas. And I 
appreciate it.
    One last thing. It does say in the article, and I would 
like to follow-up on each of these, Mr. Chairman, if I might, 
it says performance reviews and bonuses of top hospital 
administrators are linked to meeting those goals. I would like 
to see if there is a connection like that as indicated in the 
article.
    I yield back, Mr. Chairman.
    Dr. Benishek. Thank you, Mr. Huelskamp.
    Ms. Negrete-McLeod.
    Ms. Negrete-McLeod. [Nonverbal response.]
    Dr. Benishek. Dr. Ruiz.
    Dr. Ruiz. Thank you for being here. I thank you for your 
service and thank you for all your hard work.
    We definitely have to continue your efforts. There is a lot 
of problems that we need to fix and I appreciate that we are 
moving in the right direction albeit it perhaps impatiently 
slow, but we have to continue to move in that direction.
    You know, Mr. Matkovsky, I wrote a letter to you dated 
February 6 about procuring three ultrasound machines for my 
regional VA hospital. They have been waiting for a long time to 
get three simple ultrasound machines.
    When I was in Haiti after the disaster as the medical 
director for the largest internally displaced camp in Port-au-
Prince with about 60,000 Haitians living under sheets and 
sticks in the midst of our western hemisphere's most severe 
disaster, we needed ultrasound machines.
    And I made a phone call to a local hospital in my area. Two 
weeks later, we get an ultrasound machine. And you talk about 
logistical nightmares. You talk about bureaucracy. You talk 
about the difficulty in transporting ultrasound and getting the 
right one, et cetera, to an earthquake stricken country.
    Why does it take so long to get those ultrasounds? Two, 
when can we get those ultrasounds?
    Mr. Matkovsky. Thank you, Congressman Ruiz.
    That letter is actually being responded to by Mr. Frye. He 
is our senior procurement executive as well. I think it was co-
addressed.
    If I may, I may just address a little bit of the 
consolidation process that we have historically used in VA. We 
have a national acquisition center that has all of our national 
contracts for what we call high cost medical equipment. The 
high cost, high tech ultrasound, MRIs, CT scans, et cetera, are 
all acquired through that central service.
    What we have typically done historically is we consolidate 
our purchases. We did that under the premise that through 
consolidation, we would achieve better price competition and 
then achieve some measure of return.
    We have looked at that process in 2012. At the end of 2012, 
our consolidation was 909 pieces of equipment. These ultrasound 
machines were part of that consolidated purchase. We expect to 
finish all of the delivery orders for those by April of this 
year.
    So in answer to your question, the delivery orders, if they 
have not been issued, will be issued by April.
    Now, we are looking at that process and figuring out how we 
can do it a little bit faster and a little bit different.
    Dr. Ruiz. Can I ask you a question there?
    Mr. Matkovsky. Yes.
    Dr. Ruiz. You said delivery orders. My goal is the end 
goal, the actual outcome. So tell me the time it takes between 
delivery order and then actually the Loma Linda VA receiving 
the ultrasound.
    Mr. Matkovsky. Sir, I do not have an answer for that. That 
would depend on the manufacturer that gets the ultimate 
delivery order, but it can be as quick as three months or less 
depending upon the manufacturer.
    We ran a separate process. Let me just--I can see your 
expression, sir. So we ran a separate process as a result of 
our roundtable which Chairman Benishek and Ranking Member 
Brownley held. And we carved out some different cost items, 
portable x-rays, C-arms, and we ran those at the network level 
in VISN 15 which is the heartland of the country, Missouri.
    And those that we purchase through that process from the 
beginning of the requirement through the actual contract award 
was 90 days, right, as compared to 400 or so days for a 
consolidated process. That equipment began arriving, the 
portable x-rays began arriving before the end of calendar year 
2013. Start to finish, less than six months.
    Not exactly the same as your Haiti example, but 
considerably faster. We are going to try that again in Network 
23 just to make sure we can iron out some of the kinks and we 
are going to use that process system-wide from here on out once 
we finalize just a couple of details.
    We hope that is going to speed it up a lot and then we are 
also going to look at the consolidation process and change that 
as well.
    Dr. Ruiz. Thank you very much.
    I am going to continue to follow the natural life history 
of requesting three ultrasound machines until they are born in 
the womb of our Loma Linda VA Hospital. So, you know, thank you 
so much and I will follow-up with you.
    Dr. Benishek. How long has it been that this is going on?
    Dr. Ruiz. How long has it--it has been two years, my 
friend, two years for three ultrasound machines.
    Dr. Benishek. All right.
    Mr. Matkovsky. It is too long, I agree.
    Dr. Ruiz. Thanks for that.
    Dr. Benishek. Five minutes for Dr. Wenstrup.
    Dr. Wenstrup. Thank you, Mr. Chairman.
    I appreciate you all being here today.
    And forgive my ignorance on my first question, but I am 
curious if any of you have ever as doctors been in private 
practice where you ran your own business. Have any of you been 
in private practice?
    Dr. Petzel. I have not. I have worked in academic medicine, 
but not private practice.
    Dr. Wenstrup. Okay. Because this is where I draw the line 
on so many things. For example, if the VA hospitals and their 
providers operated under Medicare rates, for example, or even, 
say, 105 percent of Medicare rates and providers were paid fee 
for service, do you think the VA hospitals would be in the 
black?
    Dr. Petzel. Yes, personally I do. We have done several 
studies going back as many as ten years and looked at our cost 
to providing a service as opposed to the private sector cost of 
providing a service or compared to the Medicare reimbursement. 
And in virtually every instance, we are talking 15 to 25 
percent less cost associated with providing that service. So, 
yes, I think we could survive very well on Medicare rates, very 
well.
    Dr. Wenstrup. Because there is a part of it sometimes that 
makes me curious as to what motivates the VA system, the way it 
is funded, et cetera, to really be effective and efficient 
compared to, say, private practice because I have operated 
under both systems.
    And besides personal pride in the work that I do and 
besides motivated to try and see as many patients as I possibly 
can effectively, those are personal things, but what within the 
system motivates that?
    For example, because I found, and I will use DoD as an 
example, as a reservist in private practice, in the time that I 
would see 45 patients effectively and efficiently in my private 
practice because of the way military hospitals are set up and 
the physician staffing, et cetera, I could only see 15. I mean, 
that is just a fact.
    And I have offered to you in the past to come into the VAs 
and work with you on the staffing issues. And I have not heard 
anything from anybody on that, and I mentioned it to Secretary 
Shinseki as well.
    So what within the system motivates, stimulates the entire 
system to be extremely effective and efficient? What does that?
    Dr. Petzel. Well, thank you, Congressman Wenstrup. That is 
an excellent question.
    First of all, it is the mission. I mean, we are taking care 
of people who have earned and deserve the care that we are 
delivering.
    The second thing is that we have an unlimited demand on the 
service with a limited budget. We do not generate more money if 
we do more work. We get our budget at the beginning of the year 
and we have to take all comers because of that. That has driven 
tremendous efficiencies in this system, tremendous 
efficiencies. We roll by one to 1.5 percent in terms of the 
number of people we treat every year.
    Our models for funding have in them productivity standards 
which say that we have to increase our productivity by one to 
two percent every year. That is a tremendous, tremendous 
motivator. I would match our efficiency and our cost of doing 
business against the private sector at any time.
    Dr. Wenstrup. Okay. In the effort that you are making with 
providing appropriate staffing, you know, in our private 
practices, are we increasing our staffing so that we can treat 
patients more effectively, increase access, things like that as 
well as have good outcomes? You know, there is a real number 
value to that.
    So are you doing a follow-up on that that will show, yes, 
we are now seeing more patients at least cost and being 
efficient and will we have access to those types of numbers?
    Dr. Petzel. I would ask Dr. Agarwal to comment on that.
    Dr. Wenstrup. Sure.
    Dr. Agarwal. This is an excellent question, sir. And that 
is exactly what we recently asked since we have provided these 
tools to our local managers in managing these resources as to 
how it is that they are using it to make the clinics much more 
efficient and ensure that all the specialists are working at 
the top of their license. And the information that we have 
gotten back has actually been very good. Managers are looking 
at the resources that they are providing to the clinics and 
understanding what is the output, what is the value that they 
are achieving I think was made possible by these tools. So to 
be able to tell a specialist that you need to spend more time 
in the clinic or take care of, certain groups of patients has 
been possible because now when the access data and the 
productivity is aligned and it is sort of placed in a way that 
people can understand much better, it gives you insight into 
whether additional resources are needed or enough resources 
have already been provided but some other changes need to be 
made in specialty clinic. So we believe that in the longer run 
once this becomes the norm in how we practice, especially with 
the resource management part, this is going to be extremely 
beneficial.
    Dr. Wenstrup. Yes, I think it can be. I mean, assuming you 
are going to see everyone eventually that needs care we 
actually have a tremendous savings if we see them sooner and do 
it more efficiently and effectively. So you want to make sure 
that when you add a staffer it is because you get a better 
result and better outcomes.
    Dr. Agarwal. Exactly. Exactly.
    Dr. Wenstrup. I think that is what we want to hear back 
from you on over time as this is implemented.
    Dr. Agarwal. Thank you.
    Dr. Wenstrup. Thank you, and I yield back.
    Dr. Benishek. I just want to comment for a moment. Dr. 
Petzel, that answer you just gave Dr. Wenstrup, that is just 
completely ridiculous.
    Dr. Petzel. I am sorry?
    Dr. Benishek. You know, I worked at VA? In order to get the 
number of cases that I had done in the private sector in VA it 
took me a year to get the staff up to speed so I could do the 
same amount of cases at VA that I could do in the private 
sector. Motivating the staff at a VA hospital to get things 
moving and to use your time effectively is a tremendous, 
tremendous problem. And that answer that you gave, that said 
that you would put VA up against the private sector anytime, 
that is a complete fabrication of what actually occurs at the 
VA. I worked at VA for 20 years. I know that that is just not 
true. And having people from the outside who have been in the 
private sector whose time is valuable sitting in the doctor's 
office doing nothing for a half a day with you, a turnover time 
of a half an hour which is done in like seven minutes in the 
private sector is very frustrating to physicians. That kind of 
answer is not going to wash it here. With that I am going to 
give Ms. Kuster an opportunity to ask a question. Thank you.
    Ms. Kuster. Thank you very much, Chair Benishek, I 
appreciate it. And thank you to Vice Chair Brownley for your 
leadership on these issues. I have two questions, if I could. 
One has to do with a company in my district in New Hampshire, 
Salem, New Hampshire, the company is named Gamma Medica. And 
they make a medical device that produces bone density imaging 
to help with early detection of breast cancer. And my question 
is not specifically about them but my understanding is in New 
England many of our VA health facilities have requested this 
life saving device but due to over two-year-long delays many 
veterans seeking early breast cancer detection are not 
receiving the treatment that they, delays at the NAC. And my 
question, this is to Dr. Petzel, can you tell me how VA is 
actively engaged with improving delays for new technology at 
local facilities? And what steps have you taken since the round 
table last April on procurement wait times that we had to work 
with NAC on improving the amount of time it takes to deliver 
lifesaving devices?
    Dr. Petzel. I would defer in a moment to Mr. Matkovsky who 
has gone through that. But just to say that we are, we are not 
happy with the two-year process as well. The bundling, from my 
personal perspective, puts delays on this acquisition that I 
think are unnecessary. There is a compromise here between 
trying to save money by bundling on the one hand and on the 
other hand delaying the acquisitions because we are bundling. 
But Mr. Matkovsky, why do you not just go through again what 
you had said about what we are trying to do to reduce that 
time?
    Mr. Matkovsky. Yes, sir.
    Ms. Kuster. Thank you. And I apologize that I had to come 
in late.
    Mr. Matkovsky. No, that is okay. Congresswoman Kuster, the 
one thing I would state is that in our efforts to establish a 
structure that was more economical we left out a critical 
variable in history, which was speed. Our supply chain should 
also focus on speed. Procurement reform should establish 
compliant, economical acquisitions, but they should also be 
fast.
    Following our round table we did review how we do the 
consolidations. We are trying to change those. It is going to 
take us a little bit of time. The big focus was the end of 
fiscal year 2012 orders that went in. There were 900 of those. 
The bone densitometers for Gamma Medica may in that 
consolidated process. But it is not a process that is working 
in terms of speeding the new technology for application. What 
we are trying to do now is move the less complex items so that 
they can be purchased at our 21 network offices through their 
contracting officers. In a sense instantaneously you have 21 
additional work teams now focusing on it rather than just the 
one up in Chicago.
    We wanted to make sure we could test it. We found out that 
there were some clauses that were competitive with our national 
contracts. We are going to extend the test a little bit more 
and then beginning in fiscal year 2015 that will become that 
way of business. That will free up these national acquisitions 
to be a little bit faster as well.
    By April of this year we expect to be finished with all of 
the delivery orders from that last major consolidation. Then it 
will still take some time for the technology to be in medical 
center.
    Ms. Kuster. Okay. Thank you very much. My other question 
has to do with an issue that many of us have been involved with 
in the past year on military sexual assault treatment. I have 
been visiting the VAs in White River Junction and in Manchester 
and have actually been quite impressed by the protocols there 
but I am not familiar across the country.
    We had a hearing last July where we had some very 
compelling testimony from veterans. And we were talking about 
whether veterans are being adequately screened for military 
sexual trauma. I think if I recall the testimony they were only 
asked on the initial visit and they were not asked on 
subsequent visits. So I would like to hear how the VA is 
following up with the local VA health facilities to measure the 
effectiveness of screenings and follow ups and also how are you 
providing local smaller VA facilities the information and tools 
they need to train and educate providers to treat survivors of 
MST?
    Dr. Petzel. Dr. Jain was at that hearing, as you remember. 
And I would ask him to comment on the changes and improvements 
we have made since then.
    Ms. Kuster. Great. Thank you.
    Dr. Jain. Thank you, Congresswoman Kuster, for that 
question. So as you mentioned this was fairly compelling 
testimony that we heard last year. So we have taken several 
steps. First of all the entire screening has now been revised. 
So that questions are being revised. We believe that the 
questions were not very clear before so we added a little more 
clarity. We have also added an option where the veteran could 
decline to answer the question. So they could answer the 
question whenever they felt they were ready, and to whom they 
felt comfortable with answering the question. So if the veteran 
were to decline to answer the question, then within the year 
the reminder would kick back in and the question would be asked 
again so we do not lose that opportunity.
    Ms. Kuster. Oh, that sounds good. Instead of people 
assuming that that is a no answer----
    Dr. Jain. Yes, ma'am.
    Ms. Kuster [continuing]. It is a decline answer and then 
you would revisit it?
    Dr. Jain. We will revisit that. We will also have added 
actually a functionality where a third question has been now 
added. Through the pilot we learned that the veterans want to 
be referred to mental health or to specialty care and now we 
will be able to track those referrals and will be able to 
follow up through our data and numbers to see how the 
individual facilities are doing with following up on the 
reminders.
    Ms. Kuster. That sounds great. And could, I do not know if 
this would be possible to add to your protocol but I just want 
you all to be aware and maybe there is a way it could be 
factored in, we were successful in passing a bill to provide 
whistleblower protection to members of the military who come 
forward with claims of sexual assault, men and women. And I 
think it is an important piece of information because of the 
history on this issue and because of the retribution and 
retaliation in some cases in people's careers, that there was 
good reason not to come forward. And so I am hoping that you 
will find a way to incorporate this, to reassure victims to 
come forward that this whistleblower protection will be in 
place.
    Dr. Jain. We can certainly look into that, Congresswoman, 
and see how we could incorporate that.
    Ms. Kuster. Thank you. Thank you very much. Thank you, Mr. 
Chair.
    Dr. Benishek. Yes. I am going to start another round of 
questions, and I have got a couple of things. Dr. Petzel, would 
you provide the committee for the record the circumstances 
surrounding the 14 SES employees you said the VA forced to step 
down in the past two years? We would like to have that by the 
end of the week, if we could.
    Dr. Petzel. If I could clarify that, Mr. Chairman. Let me 
clarify that, sir. I had the numbers wrong. There were 14 
serious disciplinary actions taken. Six SES employees were 
dismissed over the last two fiscal years, three non-
probationary, and three first-year probationary. And we will 
provide whatever information you want related to that.
    Dr. Benishek. All right. All right, thank you. I am going 
to go back to one of the hearings that we did in the past to 
follow up. It is concerning the care and treatment of military 
sexual trauma and I think Dr. Jain was the, primary witness at 
that hearing. And I just want to follow up a bit more. You said 
we are going to take a critical look at how we structure 
services and what we can do to address some of the gaps. And 
you also said, ``I think there are many points that the veteran 
witnesses made in terms of suggestion that we would take to 
heart, and we will go back and review our current policies and 
procedures.'' So Dr. Jain, what specific actions have you taken 
to improve the situation? You mentioned, the questioning or the 
asking about sexual trauma. But what else specifically have you 
done to address the concerns that we brought up in that 
hearing, and that were brought forth by that testimony?
    Dr. Jain. Thank you, Mr. Chairman, for that question. So as 
I was just stating to Congresswoman Kuster, so the first big 
thing we did is to do a careful analysis of our screening 
process. And as I was indicating earlier----
    Dr. Benishek. All right. You went through that. But go 
through something else.
    Dr. Jain. So that was number one. Secondly, we have also 
looked at our outreach activities that we are doing. So we have 
modified our outreach posters where the male and the female, 
survivors are, included in the posters. We are also doing 
outreach with the Department of Defense so that at the time of 
transition this is an activity we have taken in the last few 
months. So as the servicemembers transition from DoD to the VA 
the information regarding MST services is now provided to them 
so they know and they understand what services will be 
available to them in the veteran status. So that is an 
improvement.
    We have also taken education and training activities. So we 
have trained the MST coordinators on the sensitivity relating 
to the male survivor issue that was presented at the hearing. 
We want to make sure that our male survivors can receive care 
in a gender sensitive manner in our outpatient clinics so they 
do not have to go for a women's clinic, for example, to receive 
services.
    We have also made sure that the----
    Dr. Benishek. That change has occurred, then, you are 
saying?
    Dr. Jain. Yes, sir. That training has already occurred. We 
have also trained the VISN leads that provide the MST services 
to monitor that activity. We also make site visits. And so we 
are tracking this as part of the site visits to make sure the 
facilities are providing the care in a gender sensitive manner. 
And then we are also doing a mystery shopper type sort of 
activity where both the male and the female staff members would 
call, randomly call the VA facilities to speak to the MST 
coordinator to just understand how will it take them to reach 
an MST coordinator, whether they are able to address the 
questions in a sensitive manner. So these are all the changes--
--
    Dr. Benishek. How is that working out?
    Dr. Jain. That is actually going quite well. We have been 
very pleased with the training and how that has taken hold.
    Dr. Benishek. Well I would like to see a report on what 
you----
    Dr. Jain. Yes, sir. We can certainly.
    Dr. Benishek. That is a great idea, I think. Having 
somebody just call in anonymously and figure out what is 
actually happening. So if I could get a report on that, I would 
like to see that.
    Dr. Jain. We would be happy to----
    Dr. Benishek. How many times you called, the response, all 
of that. I appreciate your answer there. I think I will yield 
to Ms. Brownley. I want to keep the questions coming. Thank 
you.
    Ms. Brownley. Thank you, Mr. Chair. You know, I wanted to 
also follow up on the military sexual trauma issue as well. You 
talked about the outreach that you are doing and thanks to the 
chairman we had a hearing in my district last week talking 
about mental health services but a component of that discussion 
was about outreach. And one of the problems that was discovered 
in the various testimony is that the West L.A. facility was 
doing the outreach for mental health services for Ventura 
County, and Ventura County was not providing the outreach. And 
it was clear that the West L.A. facility was not aware of all 
of the programs that were accessible to programs in the county. 
So their outreach is basically ineffective because they have no 
idea about all of the nonprofits and volunteer organizations 
and so forth that could help our veterans. So when you talk 
about outreach for the, for our victims, or survivors I should 
say, of military sexual trauma, what does that outreach really 
look like? And I know that the IG had recommended and thought 
it would be very, very beneficial to have a central sort of 
program resource list that would be, at every VA medical clinic 
or in every community-based outpatient clinic, across the 
country. So if you could respond to that, please?
    Dr. Jain. So thank you, Ranking Member Brownley. I think 
there are a couple of things that we have done so I may not 
have a complete answer for you. But part of the outreach, as I 
mentioned earlier, is with our Department of Defense 
colleagues. But the other part of the work that we have done is 
reached out to OEF/OIF counselors within our own system. As you 
know, within the VA the majority of the outreach work in the 
communities is done by our OEF/OIF counselors. So our MST team 
has now trained the OEF/OIF counselors to begin to do the kind 
of outreach that you are referring to so that we can reach out 
into the community with nonprofits and also with other types of 
resources that are out there. So I cannot honestly say to you 
that it is completely functioning. But this is part of the 
process that we are now beginning to go beyond just the DoD 
into the community.
    Ms. Brownley. Thank you. And I also wanted to get a 
clarification in the testimony. Dr. Petzel's testimony 
indicated that the VA established a benchmark of .2 full time 
equivalent employees per 100 veterans who screen positive for 
MST. So help me to understand what that means. Is that the 
equivalent of a full FTE per 500 veterans affected by MST?
    Dr. Jain. So thank you, Ranking Member Brownley, for that 
question. So the process, the way it works is that in our 
Office of Productivity and Efficiency we have created a tool 
that monitors the numbers of MST survivors that we are treating 
and the staff resources that are dedicated to treat this MST 
survivors. So from that tool what we have determined is that it 
takes on an average two staff per thousand, or 0.2 per hundred. 
The staff would include all of the mental health staff, not 
just a particular staff member. So those facilities, so the 
last report that we have available is for fiscal year 2012. For 
fiscal year 2012 99 percent of the facilities met that staffing 
standard. There was only one facility that fell off. So after 
the hearing we immediately got after that particular facility, 
developed an action plan, and since then they have made the 
corrections. The fiscal year 2013 report would be available 
within the next few weeks. And we will be able to see how the 
facilities are doing to these staffing standards.
    Ms. Brownley. Okay. Well we would certainly like to see 
that report. It is hard for me to comprehend honestly that when 
we have a veteran who is in dire need and who is experiencing 
very, very deep trauma that a .2 FTE is adequate. And I know 
you said that is from a variety of services, but kind of culled 
together it equates to a .2 FTE correct?
    Dr. Jain. So let me clarify again, Congresswoman. This is 
at a larger data trend issue. But for that individual veteran, 
we will provide them whatever services they need through our 
mental health clinic. Now what we emphasized right after the 
hearing, as you recall, some of our witnesses were very 
concerned that when the VA was not able to provide the care in 
a timely manner that we did not refer them to a non-VA care. So 
we continue to emphasize to our staff that non-VA care is an 
available option. And I think as Dr. Petzel said PC3 and the 
availability of PC3 that would happen starting April and beyond 
will make it easier to reach out to community providers. So for 
individual veterans the .2 issue does not apply. This is for 
monitoring purposes that we keep track of what staffing 
resources are being dedicated to provide the services.
    Ms. Brownley. I am just, so if that is the benchmark of 
what you are going to measure, then it is hard to measure that 
a veteran who, again, is in deep trauma in the moment that they 
need our help, if they have gotten all of the resources, 
because your measurement is going to be, you know, a .2, sort 
of a, kind of a across the board in the aggregate. So you know, 
it is, I am not sure that that is a good metric. Maybe I need 
to understand the metric in further detail. But I think we are 
all most interested, you know, in the, obviously the screening 
part that you have talked about. But when, you know, when we 
have a veteran who has gone through this kind of trauma and 
needs our help in that moment, you know, it takes a lot of, I 
think a lot of attention and a lot of support. So it does not 
translate for me.
    Dr. Petzel. Just if I could respond a little bit to that, 
Congresswoman Brownley. The metric looks at the system overall, 
that. We would be evaluating the effectiveness of caring for 
individual patients through a variety of different ways. I am 
not familiar exactly with what we do in military sexual trauma. 
But as an example with depression, they would take a survey 
beforehand, they would take a survey after one year that they 
have been treated to look at their score on a depression scale. 
Those are the kinds of things----
    Ms. Brownley. A survey which is to ask veterans----
    Dr. Petzel. Yes.
    Ms. Brownley [continuing]. How the VA responded to their 
needs?
    Dr. Petzel. Exactly. Or how did they feel.
    Ms. Brownley. Right.
    Dr. Petzel. The Beck Depression Scale measures your level 
of depression. I am just using that as an example. That is the 
kind of thing that we would use to measure the effectiveness of 
what we are doing. Not this metric of, this is just a gross way 
to say the facility appears to be devoting in the aggregate the 
resources needed. But you are absolutely right. We need to 
look----
    Ms. Brownley. But the report, I am sorry, may I just have 
one more second? But the report you are saying that was in 2012 
and we are going to get in 2013 is a measurement based on this 
metric?
    Dr. Petzel. Correct.
    Ms. Brownley. Not a survey of veterans who are survivors of 
military sexual trauma and how the VA responded to them?
    Dr. Petzel. Correct.
    Ms. Brownley. That data we will not get?
    Dr. Petzel. Not in that 2013 report. But Dr. Jain and I 
will talk about what we can do to provide you with information 
about the effect of what we are doing.
    Ms. Brownley. I yield back, Mr. Chair, thank you.
    Dr. Benishek. Thank you. Mr. Huelskamp?
    Dr. Huelskamp. Thank you, Mr. Chairman. If I might, I would 
like to follow up on a few of your questions and drill down 
some of the accountability issues with employees and these 
preventable deaths which have I guess been confirmed by the VA 
to committee staff. But in the Columbia, South Carolina, which 
were six preventable deaths, were there any employees held 
accountable for those preventable deaths?
    Dr. Petzel. Well first of all, the concept of preventable 
deaths I think requires some discussion, not here. Yes, there 
were. There were three employees at senior levels who 
resigned----
    Dr. Huelskamp. Resigned or----
    Dr. Petzel [continuing]. Under threat of discipline.
    Dr. Huelskamp. But they were not disciplined? Is that, they 
left----
    Dr. Petzel. They left before they could be disciplined, 
correct.
    Dr. Huelskamp. So perhaps, and I guess we are arguing about 
whether they were preventable deaths, they were allowed to 
resign and move on----
    Dr. Petzel. Allowed to resign? It is their right to retire 
or resign.
    Dr. Huelskamp. There is no way to hold them accountable 
when people die because of their failures?
    Dr. Petzel. If somebody wishes to retire or resign, we 
cannot prevent that from happening.
    Dr. Huelskamp. There is no way, no criminal investigation, 
nothing along those lines to hold these former VA employees 
accountable?
    Dr. Petzel. There is no criminal, there was no criminal 
charges or intent involved in any of these situations.
    Dr. Huelskamp. And then the three deaths at the Augusta, 
Georgia center? I do not know if you answered that. Was anyone 
held accountable for those three preventable deaths?
    Dr. Petzel. We had a similar situation where a number of 
people have either retired or resigned.
    Dr. Huelskamp. And of course I would hope you could provide 
that information to the committee within 30 days. The other one 
that I did not see was the VA Pittsburgh system with 
Legionnaires', and we had a hearing and it was just a shocking 
hearing to me. I guess it is arguable in your mind how many 
veterans died as a result of that, but you did indicate at 
least one actually died of Legionella. Was any VA employee held 
accountable for the failures that led to this death?
    Dr. Petzel. Yes, as I said earlier Congressman Huelskamp, 
we are in the process of evaluating the disciplinary action 
taken at Pittsburgh. It was delayed because of the criminal 
investigation, which did not allow us to do anything.
    Dr. Huelskamp. So you had a criminal investigation there, 
but you did not pursue that, no one pursued that at Columbia 
where there were six preventable deaths?
    Dr. Petzel. The IG pursued a criminal investigation. There 
was no indication, nobody raised the question of whether there 
was criminal intent at any of these other facilities.
    Dr. Huelskamp. The preventable death, at least the one that 
you confirm here, when did that occur at the Pittsburgh VA 
Center?
    Dr. Petzel. One moment, sir. July 12, 2012.
    Dr. Huelskamp. How quickly do you expect, the criminal 
investigation is complete or not and when will you move to some 
accountability action?
    Dr. Petzel. Criminal investigation by the criminal IG is 
complete. They found no criminal activity or intent. And I am 
hoping that very quickly we will have the evaluation of 
disciplinary action at Pittsburgh concluded and we will know 
what we are going to do.
    Dr. Huelskamp. Okay. I look forward to that report. And 
lastly, at the Atlanta VA Medical Center the Inspector General 
linked three preventable patient deaths to widespread 
mismanagement. Yet we heard that the Medical Center Director 
maintained no employees responsible for the mismanagement 
linked to the deaths should be fired. Is that still the case?
    Dr. Petzel. Well first of all the IG did not link any 
deaths to the activity at Atlanta. There were three mental 
health deaths but the IG made no comment in their report on the 
quality of care that was delivered to them or the course of 
action. And seven people at Atlanta have been disciplined in 
various ways as a result of that activity.
    Dr. Huelskamp. The IG's report I thought linked that to 
mismanagement issues. You are saying it did not but you 
disciplined someone anyway?
    Dr. Petzel. Yes, specifically the IG said that there had 
been mismanagement of the contract for contract mental health 
services and there had been mismanagement on the mental health 
ward. They did not link any deaths to those activities.
    Dr. Huelskamp. But you do say that seven employees have 
received some type of disciplinary action. Last we had heard in 
the Fall it was three employees received temporary written 
warnings. Can you describe the seven, the actions of the seven 
employees that were held accountable?
    Dr. Petzel. Congressman Huelskamp, I do not have the 
specifics of what happened with the seven but we certainly can 
provide that generically to you.
    Dr. Huelskamp. Well I would like it, rather than generic I 
would like it answered obviously----
    Dr. Petzel. Well we cannot name the individuals but we can 
tell you exactly what was done.
    Dr. Huelskamp. Oh, absolutely. But again, last Fall this 
committee was told there was temporary written warnings for 
three individuals and so I would like clarification. Apparently 
you have done some more since then.
    Dr. Petzel. There were, yes, at the time of the previous 
hearing there were three actions that actually had been taken 
and there were four actions pending. All have been now taken.
    Dr. Huelskamp. Okay. I look forward to that report. Thank 
you, Mr. Chairman.
    Dr. Benishek. Thank you, Mr. Huelskamp. Dr. Wenstrup.
    Dr. Wenstrup. Thank you, Mr. Chairman. You know, I 
appreciate all of your level of expertise and your medical 
backgrounds. But to be honest I am a little surprised that 
there is not people involved with administration that have been 
in the private sector. I think it would be extremely helpful. 
And I did not come to Congress to sit here and to complain 
about things but to try and bring solutions. And that is the 
drive of my efforts here.
    Let me ask you Dr. Agarwal a question on, for example, in 
an eight-hour day in the VA system on average how many patients 
would an orthopaedic surgeon see?
    Dr. Agarwal. Sir, you know, that would be hard for me to 
sort of say. If it is an outpatient clinic I would assume 
that----
    Dr. Wenstrup. I am talking about in the outpatient clinic 
setting. Assuming their surgery day is different, we can get to 
that later. But just in an eight-hour day, in the outpatient 
clinic, doing their post-ops, etcetera, how many patients do 
they see on average? And if you do not know, that is okay.
    Dr. Agarwal. I actually do not know.
    Dr. Wenstrup. Okay. See, this is the type of thing I am 
talking about when I am talking about measuring productivity. 
And you say you have been doing this, and we have talked about 
it for the last year, and you do not have an idea. So what are 
you measuring? Because I was operations chair for a 26-doctor 
orthopaedic group. These are the things we looked at and how do 
we improve our staffing so that we can be more productive and 
still provide the care. And our reputations are on the line 
with this, too. So it is important. So I would like to know 
what type of metrics you are going to use, and that goes back 
to my previous question before. And I am not trying to be a 
pain. But are you going to do something that is effective and 
efficient. And if you do not know those numbers then you do not 
even have a baseline to start with.
    That being said, let me go back to where Dr. Benishek 
weighed in having his experience at a VA and your comments to 
Dr. Petzel. You know, I am just curious to know if a VA 
hospital budget was based on the previous year's activities 
submissions at a Medicare rate, fee for service. If that was 
your budget based on your previous year's productivity, based 
on Medicare rates, you say that yes you would be in the black. 
So it would be interesting to know if that actually would cost 
the taxpayers more or less, if that is how your budget was 
based. And based on your comments it almost sounds like that 
would come in less than what we actually budget for you. And so 
would you be comfortable exploring that notion?
    Dr. Petzel. Certainly.
    Dr. Wenstrup. Thank you. And I yield back.
    Dr. Benishek. Thanks, Dr. Wenstrup. I have another question 
and I am just trying to cover the issues that we have covered 
over the last year, and one of them is the third party billing 
issue that we had talked about. Perhaps Mr. Matkovsky can 
answer this. Can you tell us about what is happening since you 
gave us the testimony there? Are you, are you collecting 
better? Have you changed anything since I talked to you last? I 
have got a couple of follow ups, too.
    Mr. Matkovsky. Yes, sir. We covered two topics there. One 
of them was non-VA medical care. And if you want I can give you 
a little update on where we are with----
    Dr. Benishek. Well let us start with the collection----
    Mr. Matkovsky. Yes, sir.
    Dr. Matkovsky [continuing]. Because that is what we are 
here for. And then for collections, as a result of that round 
table discussion we had public requests for information, which 
is a precedent to a request for proposals, to look at are there 
industry systems that would allow us to automate the billing 
process a little bit better. When we analyzed the turn around 
time for billing we noticed that one of the longest times that 
it takes us is actually from the outpatient event, the 
inpatient event, to the generation of the bill. And a lot of 
that is because of the manual process. So we had a competitive 
RFI, request for information, and we are evaluating those 
responses. We are also working with our IT organization to 
determine whether or not the systems enhancements would be 
considered IT and subject to that funding or whether we could 
use them under administrative funds.
    Dr. Benishek. All right. Okay. Well I think that gives me 
an idea of where you are at.
    Mr. Matkovsky. Yes, sir.
    Dr. Benishek. The only other question, I know you talked 
about this PC3 thing and you kind of led me to believe that 
this is going to help solve the problem of getting outside care 
to our veterans in a more timely fashion. But my concern 
frankly is two things. The reimbursement rate that providers 
are going to be provided through VA. And like sort of what is 
the take from the insurance people? What percentage of the 
total spending is going to be made to get these third party 
networks on board? Can you tell me about that?
    Mr. Matkovsky. Sure. First I would tell you that we kicked 
it off in January on time. There was a little bit of a delay, 
but it is now running. It is in 47 of the initial 50 medical 
centers are referring patients through to the PC3 networks. 
There are somewhere north of 5,000 referrals that have been 
made to the network. I will tell you that our agreement, 
however, is with the intermediaries not with the firms 
themselves. So we have an agreement with TriWest, we have an 
agreement with Health Net organizations, not with their 
provider networks. However, both contractors are required by 
their contract to have a built out network for us. So the 
incentive for them is to have as competitive a network as they 
can for us to provide them referrals, and that is actually by 
the basis of the contract as well.
    Dr. Benishek. But the question I asked was the 
reimbursement to the providers, what level is that going to be 
at? And what percentage of the total money that you are 
spending on TriWest or wherever it is, what percentage of the 
total spending is going to go to their management fees and 
which is going to go to actual provider care? Do you 
understand?
    Mr. Matkovsky. Yes I do, sir. So there----
    Dr. Benishek. Can you answer that question?
    Mr. Matkovsky. I will.
    Dr. Benishek. Or is it not available?
    Mr. Matkovsky. First of all, our agreement is with TriWest 
and Health Net. Not with their subcontractors. Second of all, 
though, the structure of the contract is that we pay at a CMS 
rate to TriWest and Health Net and then they will have a rate 
somewhere below that but we are not privy to that. There is an 
administrative fee which is separate to the direct clinical 
fee, which TriWest and Health Net would also bill us. And we 
expect that their administrative charges would be captured 
there and not to the detriment of their network. There are 
incentive structures in the contract as well. So based on the 
ability of those organizations to build out their networks they 
get an incentive payment as well.
    Dr. Benishek. So there is a separate administration fee?
    Mr. Matkovsky. Yes, sir.
    Dr. Benishek. And then there is a payment that you are 
saying is based of off Medicare rates to the providers?
    Mr. Matkovsky. Yes, sir.
    Dr. Benishek. Or that is to Tricare, and they are going to 
pay the providers less than that then? Is that what you said?
    Mr. Matkovsky. We are not privy to the information about 
their agreements with their subcontractors.
    Dr. Benishek. Well I am just trying to be sure that the 
system actually is able to procure providers. Because if 
somebody is offering, a very low rate of reimbursement you are 
not going to get very many people to sign up.
    Mr. Matkovsky. So far we are not seeing it, be the case 
across the country. That we are actively starting up the sites 
where we are. In VISN 23 it is up and running. There are a 
number of referrals. We should not be seeing the inability to 
build out networks at this point.
    Dr. Benishek. All right.
    Ms. Brownley. Thank you, Mr. Chair. And I will promise you 
I will watch my time. I wanted to go back to the one question 
that I did not think got answered. Maybe it did but I did not 
hear it about the IG's recommendation for establishing a 
central program resource list for MST related programs? Is that 
something the VA is going to do? Or believes that it is also 
beneficial?
    Dr. Jain. I am not sure, Congresswoman Brownley, about the 
question. I am not aware of any central program list in the OIG 
recommendation that is outstanding that I know of. The only one 
that we know of that is outstanding is the whole issue of 
travel and any travel issue. That was the only one that we were 
aware of. The only other thing that does occur to me, so there 
was one issue in OIG, yes, I do recall. And that was the issue 
that within the VA's intranet there is the availability of 
different programs and who are the MST coordinators. And we 
have addressed that concern and we have updated that list, make 
sure that the staff is aware that when they need to refer a 
patient to a larger VA, for example, for MST related services, 
who is the contact person? Who do they need to contact? That 
has been updated and has been addressed.
    Ms. Brownley. Okay. Thank you very much. And I just wanted 
to go to the issue of chronic pain and I am wondering about in 
testimony before we have had testimony with the Tampa Chronic 
Pain Rehabilitation Program and sort of what are we learning, 
you know, best practices, lessons learned there?
    Dr. Petzel. Congresswoman Brownley, let me make a couple of 
comments then I am going to turn it over to Dr. Jesse, who was 
at that pain, at that hearing. The VA has developed what I 
think is probably the most robust pain management program for a 
large integrated delivery system in the country. The Tampa 
inpatient program for pain management is an example of the 
kinds of services that we have to offer. We have taken very 
seriously the problem with opioid management and pain. I think 
the physicians in this room will remember that 15 years ago it 
was felt that pain was undermanaged, and pain medications were 
pushed. You need to get rid of the pain. That has obviously 
led, and I am not talking about the VA, I am talking about 
medicine in general, led to a problem in this country of the 
overuse of opioids in managing pain. And the VA I think is very 
seriously addressing that problem. And Dr. Jesse?
    Dr. Jesse. Thank you. So there are some very long and 
detailed explanation I can give. I think the VA has a very good 
story to tell. But if coming back specifically to Tampa, Tampa 
is an inpatient rehabilitation facility that is unlike almost 
anything else you can get. That a patient get this without 
paying out of pocket is unheard of in this country. It is a 
CARF-accredited program. In 2000, we had I think one CARF-
accredited program. We now have ten. We have 14 in process, 
that accreditation process. Our goal is to ensure that every 
VISN, every network has at least one. And that is part of the 
overall strategy that Dr. Petzel referenced of a stepwise pain 
management program, beginning with a very comprehensive base in 
primary care including the ability to use therapies other than 
pharmacologic. You heard about acupuncture, about medication, 
imaging therapy, behavioral therapy, and escalating, the 
ability to have consultation from pain experts, and escalating 
up to the higher level pain centers where in fact we use a 
much, we can use much more technical programs like spinal 
stimulation, which was discussed at the last hearing, like 
nerve blocks, injections, thermal nerve ablations. And frankly 
those are the kind of very intensive inpatient rehabilitation 
programs that Tampa offered.
    Ms. Brownley. So you believe that that is moving really 
across the country in terms of looking at all of the 
alternative therapies that you just suggested?
    Dr. Jesse. Oh yes, absolutely. And so, you know, we have 
our, we have as part of this strategy not just the opioid 
safety initiative, which is key, but it is also the ability to 
use other strategies to relieve pain rather than just masking 
them, that is not the right way to say that, but rather than 
just using, you know, pharmacological therapy. So for instance 
as part of the joint program with the Department of Defense 
there is a program called ATAX, I think is the acronym, I do 
not remember exactly what it stands for, but it is to train 
acupuncturists in what is called battlefield acupuncture, 
auricular acupuncture. Relatively effective at managing pain. 
The goal, we presently have I think just shy of 20 trainers. 
The goal is to have 400 enrolling that program out. Developing 
that capacity is key. And you know, frankly the whole goal of 
VA as we have discussed in the past is to provide personalized, 
patient driven care. Which really includes a wholesale 
embracement of I think what the industry would call integrative 
care, integrative medicine. And that is, you know, that is part 
of our fundamental plan of healthcare deliver in VA.
    Ms. Brownley. Thank you. I will yield.
    Dr. Benishek. Thank you, Ms. Brownley. Dr. Jesse, I also 
want to ask a couple of questions on that.
    Dr. Jesse. Sure.
    Dr. Benishek. On our pain hearing that we had. And I do not 
know, I just want to hear that specifically, you give some, 
generalized answer here. But specifically since our hearing, 
what have you done to educate the physicians within VA about 
pain management? What has anything changed since our hearing 
last year? What have you done?
    Dr. Jesse. If I may, clearly things have changed because 
since the hearing last year there are 20,000-some fewer 
veterans on opioids. You know, we have been rolling out these 
initiatives not since the hearing but literally since, for four 
to five years. They take time to get in place, they take time 
to build the infrastructure. The opioid safety initiative began 
to be rolled out prior to that hearing and since the hearing 
there has been a significant acceleration of that. The pilots 
at Minneapolis, for instance, there has been over a 50 percent 
reduction in the use of opioids. There is a, what is called 
JPEP, it is the Joint Pain Education Program that is done, run 
jointly with the Department of Defense. Because as we have 
discussed in the past one of the key issues, and this came up 
in the past hearing if you remember, we do not want a lapse 
between somebody who is being treated on the military side and 
coming over to the VA. And part of that is to ensure that we 
actually have the same approaches to managing pain across the 
spectrum of the delivery systems, the military system and into 
the VA system. So that program is being rolled out. As I 
mentioned, the acupuncture training program is ramping up. So 
yes, there are a number of issues that are in play that have 
been much more accelerated since that past, that past hearing.
    The Post Deployment Health has calls that average about 400 
people on those monthly calls. We have another set of specific 
pain management calls that have been averaging about 300 in the 
past several months, it is moving up to close to 400. Primary 
care providers are mostly engaging in these calls. So I think 
the answer is yes. There is concrete and accelerated activity 
in these areas.
    Dr. Benishek. Well I thank you for that answer. I do not 
mean to be overcritical. We just went to the West L.A. Medical 
Center and, met with a couple of their pain specialist 
providers. And the system they had in place there, at least the 
way they explained it to me, it sounded like it was actually 
pretty effective with, alternative modalities, being 
incorporated, and having the pain specialist involved in the 
case at a certain level. And they had a pretty good criteria. 
And so I do not mean to say that everything is bad. But the 
purpose of today was for me to get a follow up on what, is 
happening. Because I hate to have these hearings where we bring 
up these issues and then, nothing else gets done. I do not know 
the follow up being done. So I truly appreciate you all being 
here today for me to try to get some more information.
    I understand Dr. Wenstrup has a follow up question he would 
like to ask.
    Dr. Wenstrup. Thank you, Mr. Chairman. Actually sort of on 
that subject, do you know what percentage of the VA hospitals 
are participating in the prescription drug monitoring programs 
in cooperation with the states?
    Dr. Petzel. That is a very good question, Congressman. 
Everybody is querying, that is our providers are asking the 
state about their patients. As near as we know, that is 
happening across the country. The reporting of our activity is 
an IT issue. We have six pilots in places like Kentucky and 
Tennessee, which have been very successful and the process is 
in place now to roll this out to the rest of the country. The 
limitation is IT, is getting the right people, it is complex. 
You have got different reporting phenomena in each state. And 
you have got 152 medical centers. And getting that stuff 
married up IT-wise is taking us some time.
    Dr. Wenstrup. Is there anything we can do?
    Dr. Petzel. Oh dare I say it, IT money. You know. IT is our 
lifeblood. You know, everything anymore that we do in medicine 
has an IT component to it one way or the other. But I think 
that the money is in place to do this. The people are in place 
to do it. It is just a matter of getting it done.
    Dr. Wenstrup. Do you have a timeline, do you think? We have 
a pretty big problem in my district with prescription drug 
abuse. It has been cracked down on----
    Dr. Petzel. In----
    Dr. Wenstrup. In Ohio.
    Dr. Petzel. In Ohio.
    Dr. Wenstrup. Yeah. And it has been cracked down a lot. We 
have closed down a lot of the pill mills. That has all been 
done at a local level within the state. But it is still an 
existing problem. Plus, we border other states. Some sometimes 
we have got it within Ohio, but not necessarily in the other 
states. And having the VA information would be helpful as well.
    Dr. Petzel. It is. And I would like to take for the record 
the question of how long. And we will get back to you quickly 
about exactly what the timeline is.
    Dr. Wenstrup. Okay, thank you.
    Dr. Petzel. Just a little bit about that, it is very 
important and from our perspective to know the prescriptions 
are going on on the outside.
    Dr. Wenstrup. Right.
    Dr. Petzel. Are people, doctor shopping? Are they using 
other people? And it is important for the states to know what 
we are doing----
    Dr. Wenstrup. Right.
    Dr. Petzel [continuing]. So that they can put that and make 
that information available to the private sector. This is very 
important.
    Dr. Wenstrup. It is helpful both ways, there is not doubt 
about it.
    Dr. Petzel. Yes, absolutely.
    Dr. Wenstrup. Thank you, and I yield back.
    Dr. Benishek. Well I think that concludes the questions 
that we have today. I do have to ask before we adjourn that we 
do have some further written questions we would like to have 
submitted for the record. I suspect that you guys hopefully 
will get those answers to us. There is a lot of lengthy stuff 
there that I would like to get some follow up for but we do not 
need to have it here today.
    Dr. Petzel. Yes, sir.
    Dr. Benishek. So I appreciate you all being here. I ask 
unanimous consent that all members have five legislative days 
to revise and extend their remarks and to include extraneous 
materials. Without objection, it is so ordered. And the hearing 
is now adjourned.
    [Whereupon, at 11:40 a.m., the subcommittee was adjourned.]
                                APPENDIX
         Prepared Statement of Hon. Dan Benishek M.D., Chairman
    Good morning and thank you for joining us for today's oversight 
hearing, ``VA Accountability: Actions Taken in Response to Subcommittee 
Oversight.''
    Almost one year ago today--during my first hearing as Chairman of 
the Subcommittee on Health--we met to discuss the persistent lack of 
productivity and staffing standards for specialty care services at 
Department of Veterans Affairs (VA) medical facilities.
    We learned that VA had yet to implement such standards despite more 
than thirty years of reports and recommendations directing the 
Department to do so.
    I was so alarmed by VA's decades-long lack of action that I quickly 
introduced H.R. 2072, the Demanding Accountability for Veterans Act.

    H.R. 2072 would:

         Require VA to ensure that IG recommendations 
        concerning a public health or patient safety issue were 
        addressed;
         identify those within VA medical facilities who are 
        responsible for implementing needed changes; and,
         prohibit VA from awarding a bonus or performance award 
        to any employee who does not fully address a recommendation 
        under his or her purview.

    The goal of this legislation is to create a culture of 
accountability within VA--a culture where problems are identified and 
immediately corrected and leaders are held responsible for their 
actions.
    Were H.R. 2072 in place thirty years ago, VA would have been 
required long before now to implement productivity and staffing 
standards for all specialty care services and who knows how the health 
and well-being of the veterans seeking care through VA would have 
improved as a result.
    I wish I could say that first hearing was the only time that we 
have seen evidence of a lack of timely action taken by VA in response 
to serious problems.
    Unfortunately, that is not true.
    Since the conclusion of that hearing, we have held other hearings 
and roundtables on topics ranging from the care provided to veterans 
with chronic pain and who have experienced military sexual trauma to 
concerns regarding Department-wide procurement reform and third-party 
collections.
    At each of these oversight forums, we heard example after example 
of VA failing to act swiftly to address important issues or respond to 
the Subcommittee's requests for information in a timely manner.
    I am a surgeon by trade.
    When a serious problem is identified, my instinct is to act without 
delay to cut out what needs cutting out and fix what needs fixing.
    And, while I understand that large-scale changes often happen 
slowly--especially where large government bureaucracies like VA are 
concerned--I think we can all agree that our veterans deserve more than 
what we have seen in the last year.
    I am hopeful that H.R. 2072 will be heard on the House floor in the 
coming weeks.
    However, I am not content to wait for what can oftentimes be a 
lengthy legislative process to ensure that VA is on track to address 
the many issues the Subcommittee identified through last year's 
oversight efforts.

    During today's hearing we will:

         Assess the progress, if any, that VA has made in 
        response to the Subcommittee's hearings and roundtables;
         Determine whether appropriate steps have been taken to 
        ensure accountability when and where deficiencies in care have 
        been highlighted; and,
         Identify what further actions may be necessary to 
        improve the care and services provided to our veterans.

    Though the topics we will address today are wide-ranging, they are 
undoubtedly interconnected.
    If we do not ensure that the Department is on track to implement 
appropriate productivity and staffing standards, then we cannot be sure 
that we have the right staff in place to care for veterans experiencing 
chronic pain.
    Similarly, if we do not ensure that VA is taking all necessary 
actions to improve the collection, where appropriate, of third-party 
revenue, then we cannot be sure that we are collecting every available 
dollar that could then, in turn, be used to improve the care and 
services provided to veteran survivors of military sexual trauma.
    Last week, I had the privilege of conducting an oversight visit to 
the West LA VA Medical Center.
    During my conversations with the clinicians and support staff 
there, each of the issues we will discuss today were brought up by the 
providers when I asked them what needed to be improved in order to make 
it easier for them to care for our veterans.
    I cannot state enough how critical it is for VA to take 
responsibility for gaps in care and, more importantly, take immediate 
and definitive steps to address them.
    Unfortunately, I have seen little concrete evidence in the last 
year that the Department is doing either.
    Concurring with IG and GAO reports is simply not enough.
    Sending out guidelines without accountability in not enough.
    I sincerely hope that today's conversation will change my mind.

                                 

          Prepared Statement of Julia Brownley, Ranking Member
    Good morning. Today's hearing is intended to follow up on various 
oversight hearings and roundtables held during the first session of the 
113th Congress and to assess the progress that the Department has made 
in addressing the issues.
    The Subcommittee will also determine whether appropriate steps have 
been taken by VA to ensure accountability, and identify what further 
actions may be necessary in response to Subcommittee oversight.
    Last session, this Subcommittee held oversight hearings on 
physician staffing standards, care and treatment for military sexual 
trauma survivors, and VA's over-use of prescription painkillers to 
treat veterans with chronic pain.
    In addition to the oversight hearings, two roundtables were held, 
one focusing on procurement reform and access to care and one on 
billing and collecting from third-party health insurance companies for 
nonservice-connected care.
    There were many issues raised during these hearings and 
roundtables. Issues such as developing a plan to establish productivity 
standards for all specialty care services within three years, 
decreasing the amount of time it takes to procure large medical 
equipment through the National Acquisition Center, assessing the 
Department's programs for veterans who have experienced military sexual 
trauma, and ensuring the effective use of opioid therapy for patients 
with chronic pain.
    Mr. Chairman, these are but a few of the concerns that were brought 
up during testimony and conversations we had with the witnesses and 
participants during the forums.
    While we have a lot of ground to cover today, I am especially 
interested in hearing from the VA on improvements made in the MST 
program and in procurement reform.
    At the MST hearing held last session, we heard first hand the 
experiences of veterans who have found the system unfriendly and 
intimidating.
    According to the VA, fiscal year 2013 saw an increase of 9.3 
percent in rates of engagement of MST-related care at VHA. 
Additionally, VA reports an increase of 14.6 percent in MST-related 
visits in fiscal year 2013. I would like to hear from VA how they are 
addressing this increase.
    I am sure we all agree that it is critical that Congress do all 
that we can to make it easier for victims of MST to access needed 
benefits and services, and receive treatment.
    Compassion and care are a significant part of healing those that 
have been sexually assaulted.
    Turning now to procurement reform, Mr. Chairman, last session we 
held a roundtable and during that roundtable discussion, we heard about 
the long delays, some for up to two years, in the delivery of medical 
equipment.
    While I understand that VA is streamlining the procurement process 
to decrease the amount of time it takes to procure large medical 
equipment through the National Acquisition Center, I do not feel 
confident that much progress has been made in that area.
    Stakeholders continue to report increased difficulties accessing 
needed prosthetic equipment through VA and significant delays in 
contract awards at the National Acquisition Center.
    I find this very frustrating and unnecessary. I hope VA has good 
news on this front today.
    Mr. Chairman, thank you for holding this hearing today and I want 
to thank everyone in attendance. There is obvious concern for veterans 
and VA's ability to meet their health care needs.
    Thank you, Mr. Chairman and I yield back the balance of my time.
               Prepared Statement of Robert Petzel, M.D.
    Good morning, Chairman Benishek, Ranking Member Brownley, and 
members of the Committee. Thank you for the opportunity to discuss the 
progress made regarding the Veterans Health Administration's (VHA) 
physician staffing and productivity standards, treatment for Veterans 
who experienced military sexual trauma, pain management programs, and 
procurement reform. I am accompanied today by Dr. Robert Jesse, 
Principal Deputy Under Secretary for Health, Dr. Madhulika Agarwal, 
Deputy Under Secretary for Health for Policy and Services, Dr. Rajiv 
Jain, Assistant Deputy Under Secretary for Health for Patient Care 
Services, and Mr. Philip Matkovsky, Assistant Deputy Under Secretary 
for Health for Administrative Operations.
    The Department of Veterans Affairs (VA) is committed to providing 
the highest quality care, which our Veterans have earned and deserve. 
VA operates the largest integrated health care delivery system in the 
country, with over 1,700 sites of care. It is important to acknowledge 
that each year, over 200,000 VHA leaders and health care employees 
provide exceptional care to approximately 6.3 million Veterans. The 
high quality health care VA provides is consistently recognized by The 
Joint Commission and other internal and external reviews.
    I want to address the issue of accountability. The Veterans Health 
Administration is the largest integrated health care system in the 
country, providing 85 million total health care appointments last year 
and 25 million consultations at more than 1,700 VA health care sites. 
Allegations of misconduct by employees are taken seriously. When we 
learn of credible allegations of misconduct, VA addresses them 
immediately.
    When incidents occur, we identify, mitigate and prevent additional 
risks. Prompt reviews prevent similar events in the future and hold 
those responsible accountable. If employee misconduct or failure to 
meet performance standards is identified, VA takes the appropriate 
action.
    I would point out that VA appreciates and values the role that 
Congress, this Committee, VA's Office of the Inspector General (OIG), 
the Office of Special Counsel, and the Government Accountability Office 
have played in identifying areas where the VHA can improve. VA utilizes 
their insights when forming policy and taking action to strengthen our 
healthcare delivery programs.

Care and Treatment Available to Survivors of Military Sexual Trauma

    Effectively treating Veterans who experienced military sexual 
trauma (MST) continues to be a top VA priority. We are committed to 
ensuring that appropriate MST services are available to meet the 
treatment needs of both men and women Veterans. Rates of engagement in 
care and the amount of care provided have increased every year that VA 
has monitored MST-related treatment. In fiscal year (FY) 2013, 93,439 
Veterans received MST-related care at VHA. This is an increase of 9.3 
percent (from 85,474) from FY 2012. These Veterans had a total of 
1,027,810 MST-related visits in FY 2013, which represents an increase 
of 14.6 percent (from 896,947) from FY 2012.
    At last year's hearing on care and treatment available to survivors 
of MST, we discussed VA initiatives to provide counseling and care to 
Veterans who experienced MST; monitor MST-related screening and 
treatment; provide VA staff with training; and inform Veterans about 
available services. Since that hearing, VHA has made significant 
improvements in these areas. VA has implemented improvements in MST 
care to include enhanced screening, expanded telemental health 
services, and expanded guidance.
    As discussed during the hearing, VHA has a universal screening 
program for MST. A Clinical Reminder in the electronic medical record 
alerts providers of the need to screen the Veteran, provides language 
to use in asking the Veteran about MST, and documents the Veteran's 
response to the screen. Because a revision of the MST Clinical Reminder 
will be rolled out by the end of FY 2014, VHA will implement several 
changes including changing the Clinical Reminder language to make the 
questions asked more readily understandable to Veterans. Also, an 
explicit option to ``decline'' has been added, to allow Veterans to 
choose when and with whom they would prefer to disclose their 
experience. Veterans who ``decline'' are automatically re-screened 
again in a year. Although the intent of these changes is to facilitate 
disclosure, the revised Reminder language also capitalizes on screening 
as an opportunity to provide all Veterans with information about VHA's 
specialized MST services, regardless of whether or not they disclose 
having experienced MST. Veterans who express interest in MST-related 
treatment will have streamlined access to care via an option in the 
Reminder itself to initiate a referral for services.
    In conjunction with the rollout of the revised Clinical Reminder, 
VHA has engaged in efforts to provide staff with additional training on 
how to screen and respond sensitively to disclosures of MST. National 
educational resources have also shifted to clarify the importance of 
creating multiple opportunities for disclosure of experiences for MST--
for example, re-screening all Veterans who are seen in clinics for 
posttraumatic stress disorder (PTSD) or other specialty services.
    The addition of the referral question to the Clinical Reminder will 
allow for increased accountability with respect to the MST-related 
treatment provided by VHA. First, it will provide national monitoring 
data that will allow VHA to track whether Veterans who request MST-
related mental health services are able to access those services. 
Second, it will allow VHA to establish benchmarks for what percent of 
Veterans (on average) might be expected to access MST-related care 
after screening positive. Veterans who screen positive for MST will 
vary in their need and interest in MST-related treatment through VHA; 
without some indication of what percent of Veterans are interested in 
treatment, it is currently difficult to know the extent to which VA is 
reaching the subset of Veterans who actually need care.
    Given the increases in MST-related treatment mentioned earlier, it 
is important to ensure that facilities have adequate capacity to meet 
the demand for care. Analyses conducted by VHA's national MST Support 
Team established a minimum staffing benchmark of 0.2 full time 
equivalent employees per 100 Veterans who screen positive for MST. 
Annual monitoring of all VHA facilities using this benchmark 
demonstrated a positive impact on the availability of services. These 
analyses, in conjunction with the new referral question associated with 
the Clinical Reminder, will assist VHA in assessing continued progress 
towards the goal of ensuring that all Veterans who would benefit from 
MST-related care are able to readily access that care.
    During the previous hearing on MST, we discussed the geographic 
challenges some Veterans face when seeking to access care. VHA is 
providing services via information and telecommunication technologies 
that give Veterans more options and have improved access to care. 
Telemental health approaches can be used to treat most every mental 
health condition and deliver all Evidence-based Psychotherapies (EBP). 
As part of its strong commitment toward providing high quality mental 
health care, VHA has nationally disseminated and implemented specific 
EBPs for PTSD and other mental and behavioral health conditions. 
Because PTSD, depression and anxiety are commonly associated with MST, 
these national initiatives are important means of expanding MST 
survivors' access to treatments. Furthermore, several of these 
treatments were originally developed to treat sexual assault survivors 
and have a particularly strong research base with this population.
    Veterans who experienced MST can receive EBPs at every VA medical 
center and increasingly via telehealth. VHA's work in this area is 
supported by recent research, including research conducted within VHA 
that has shown these therapies to be effective and well-accepted by 
patients when delivered. VA administrative data indicates that from FY 
2011 to FY 2013 psychotherapy telemental health encounters with 
Veterans with primary diagnosis with PTSD has increased more than 3-
fold and during the same time frame, the number of unique Veterans with 
primary diagnosis of PTSD receiving psychotherapy via telemental health 
has more than doubled. This is due in part to national VHA efforts to 
expand the use of telehealth to providing care, particularly to 
Veterans with PTSD.
    In September, an Information Bulletin was distributed to Veterans 
Integrated Service Network (VISN) leadership that provided guidance on 
the importance of protected time for the MST Coordinator, ensuring 
facilities have sufficient capacity to provide MST-related care, and 
clarification that non-VA (fee basis) care can, and should, be provided 
when there will be a delay in the facility's ability to meet a 
Veteran's treatment needs, or if it is otherwise clinically indicated 
for the MST-related care to be delivered at a non-VA facility. The 
Information Bulletin also underscored the need to ensure adequate 
services are available to meet the needs of male Veterans who 
experienced MST and that these services are provided in a manner that 
recognizes some of the unique challenges men may face in accessing care 
and in their recovery more generally. The revised MST Clinical Reminder 
will include a mental health services referral question, which will 
streamline access to care for Veterans who express interest in MST-
related treatment. In recognition of this, at a national level, MST is 
clearly defined as an issue of concern for both men and women, in that 
it has been under the administrative oversight of the national Mental 
Health Services program office since 2006.
    In 2013, VHA concurred with the Office of the Inspector General's 
recommendation to review existing VHA policy pertaining to 
authorization of travel for Veterans seeking MST-related treatment at 
specialized inpatient/residential programs outside of the facilities 
where they are enrolled. VHA agreed to establish a workgroup to review 
the issues and provide recommendations to the Under Secretary for 
Health. After reviewing current policies, the workgroup confirmed that 
currently, MST status does not in and of itself qualify Veterans for 
reimbursement of travel expenses (called Beneficiary Travel) and 
drafted an initial proposal discussing potential options for addressing 
this issue. The work group has been directed to conduct further 
analysis and reach consensus on a recommendation.

Department-Wide Acquisition Reform

    The Subcommittee also hosted a number of roundtables to examine the 
impact Department-wide acquisition reform has had on access and quality 
of care for Veteran patients and opportunities to improve patient care 
in addition to the authority to bill and collect from third party 
health insurance companies. We discussed the processes used to provide 
non-VA care for Veterans and how billing was conducted following the 
care being delivered. We also discussed VA standards for claims payment 
and performance metrics used to track VA results as well as the 
consolidation of billing and the improvements and efficiencies 
recognized from the changes.
    Since the roundtable discussions, the Department has expanded its 
use of authorities to acquire care from community health care 
providers. In January 2014, we successfully launched delivery of 
healthcare through Patient Centered Community Care (PC3) contracts, 
beginning a phased deployment across the VA health care system. This 
new program employs nation-wide contracts to improve Veterans' access 
to quality health care. These contracts also standardize our referral, 
authorization and payment processes. Our phased deployment will achieve 
delivery of health care through PC3 across all VISNs in April of 2014.
    VA completed its consolidation of billing through the Consolidated 
Patient Account Centers (CPAC) in September 2012. This effort was 
completed ahead of schedule, and has improved the reliability and 
performance of our billing and collection processes. Since our 
roundtable discussions we have conducted requests for information 
through the Federal government procurement system to identify 
commercial best practices for automation of health care billing 
systems. This approach was a direct result to the discussions conducted 
at the roundtable, and it allows our VA team to collect competitive 
information from numerous firms. We are now processing responses and 
assessing how best to further develop a solicitation to improve our 
automation of hospital billing.
    Additionally, we met with the Health Subcommittee regarding claims 
payment timeliness. We have established a nation-wide effort to improve 
the timeliness of all claims VA pays to providers who provide 
authorized care to Veterans. We are currently working with our legacy 
systems and have increased oversight of our claims payment processes. 
We have partnered with our Department colleagues to develop a fully 
automated and commercial claims payment system that will enable 
improved and sustainable performance in our payment processes. This 
system is in field-testing in one of our networks and will complete 
development by the end of this calendar year, with a subsequent 
national roll-out and training for all our claims payment staff by the 
end of FY 2015.
    We have welcomed the involvement from this Subcommittee during our 
roundtables, which has informed the continued improvements in our 
administrative processes.

Physician Staffing and Productivity Standards

    At last year's hearing, we discussed how VHA was addressing 
productivity and staffing beginning with Primary Care Services followed 
by Radiology and Mental Health. We also discussed the complexities 
associated with measuring productivity in a health care setting. VHA 
reported in March 2013 that more than 54 percent of its physician 
workforce had standards in place to measure their productivity and 
efficiency.
    Today, I am pleased to report that we are on target to deliver 
productivity and staffing standards for all VHA physicians by the end 
of FY 2014. In October 2013, VHA briefed the OIG on its progress on 
developing and implementing specialty physician productivity and 
staffing standards. Based on VHA's briefing, the OIG closed out its 
``Audit of Physician Staffing Levels for Specialty Care Services,'' OIG 
report 11-01827-36, in November of 2013. The work continues and we will 
not be finished until all physician specialty productivity and staffing 
standards are complete and ready access to high quality, efficient 
specialty care is available to our Nations Veterans
    Today, I'd like to share with you some of the details of what we 
have accomplished and assure this Subcommittee of VHA's commitment to 
the results-oriented approach we have taken in accomplishing the 
implementation of physician productivity and staffing standards. VHA 
has adopted an activity-based productivity and staffing model for 
specialty physicians. Utilizing an industry accepted Relative Value 
Unit (RVU)-based model, specialty physician productivity standards have 
been developed and implemented. In FY 2013, productivity standards for 
six specialties (dermatology, neurology, gastroenterology, orthopedics, 
urology, and ophthalmology) were developed, piloted in four VISNs 
(VISNs (7, 12, 19 & 22)) and then implemented VHA-wide in FY 2013. All 
VISNs and medical centers were informed of the new productivity 
standards for the six physician specialties listed above on July 26, 
2013. The standards were implemented VHA-wide on September 30, 2013. By 
the end of March 2014, VHA will have productivity and staffing 
standards in place for 25 different specialties representing more than 
81 percent of its total physician workforce.
    A critical component of the productivity and staffing standard 
implementation is the Specialty Productivity-Access Report & Quadrant 
(SPARQ) tool that provides an algorithm for the effective management of 
VHA's specialty physician practices. This tool is designed to assess 
VHA specialty physician practice business strategies and drive 
performance improvement in Veteran access to specialty care. This tool 
was recognized by our OIG colleagues as one of the most important 
managerial tools developed in support of physician productivity and 
staffing standards and its ability to go beyond standard implementation 
to ultimately drive system performance.

    The SPARQ tool includes important measures, such as support staff 
ratios for VHA specialty physicians so as to maximize physician 
efficiency. The SPARQ tool measures the care team, including advanced 
practice providers such as Nurse Practitioners, Physician Assistants, 
and Clinical Nurse Specialists, and their RVU contribution. The SPARQ 
tool also measures specialty physician value in the form of 
`compensation per RVU' so as to demonstrate VHA's ability to be good 
stewards of public health care resources. Additional views for local 
medical center and VISN leadership have been added to permit a view of 
all specialties so that local leaders can make informed decisions about 
specialty care resources and be accountable for these decisions.
    VHA has also undertaken a comprehensive education and communication 
plan about the specialty physician productivity and staffing standards. 
VHA has held national calls to actively engage its specialty physician 
workforce. VHA specialty physicians are committed to demonstrating and 
improving specialty productivity and access. VHA has also held national 
calls with its medical center leadership in an effort to clearly 
communicate the expectations of full implementation of specialty 
physician productivity and staffing standards. All medical centers have 
been provided with access to a variety of tools that permit 
productivity and staffing measurement at the individual physician and 
specialty practice level. Our national and local specialty leaders have 
been trained on the business strategies and tools available to assist 
them in managing their specialty practices with the goal of ready 
access to quality specialty care for our Veterans.

VA's Pain Management Programs and the Use of Medications to Treat 
Veterans

    At last year's hearing, we discussed how VA is providing 
comprehensive and patient-centered pain management services to improve 
the health of Veterans. We also highlighted VA's current pain 
management strategies, the prevalence and use of opioid therapy to 
manage chronic pain in Veterans who are potentially at increased risk 
for a medication-related adverse event such as someone taking a high 
dose of an opioid at the same time as taking a benzodiazepine 
medication, the challenges of prescription drug diversion and abuse 
among Veterans, and the actions VA is taking to improve the management 
of chronic pain.
    Today, we are providing an update on our progress and the on-going 
challenges that we are working on in order to provide the best care to 
our deserving Veterans when it comes to managing their pain. This 
includes the integration of both medications and non-pharmacologic 
evidence-based strategies.
    Veterans enrolled in VA's health care system suffer from higher 
rates of chronic pain than the general population.\1\  Almost 60 
percent of Veterans returning from the Middle East and more than 50 
percent of Veterans in the entire VA health care system experience some 
form of chronic pain. Many have survived severe battlefield injuries, 
resulting in life-long severe pain related to damage to their 
musculoskeletal system, as well as permanent nerve damage, which can 
impact their emotional health and brain structures. Many have also 
incurred head injuries, collectively referred to as traumatic brain 
injuries (TBI), which can compound psychological injuries such as PTSD. 
The extent and complexity of these multiple conditions can make 
effective pain management difficult and increase the risk for 
complications, due to both over-and under-treatment, including overdose 
and suicide.
---------------------------------------------------------------------------
    \1\ According to a 2010 Institute of Medicine estimate, the rate of 
chronic pain in the general population is approximately 32 percent.
---------------------------------------------------------------------------
    In 2011, the Institute of Medicine (IOM) issued their report 
describing general deficits in the training of U.S. health care 
professionals in pain management. VA's health care system had 
identified and broadly responded to these deficits starting in the late 
1990s through policy, education and training, clinical monitoring, and 
the expansion of clinical resources and programs. For instance, VA 
recognized that in the management of pain, and for mental health 
problems such as PTSD, that can accompany combat injury related pain, 
there may be value to non-medication treatment approaches, including 
evidence-based psychotherapy and complementary and alternative medicine 
(CAM) approaches such as meditation, animal-assisted therapies and 
acupuncture. Several of these approaches are in active use and are 
under ongoing evaluation.
    VA recently developed and implemented an Opioid Safety Initiative 
program to better ensure opioid pain medications are used safely, 
effectively and judiciously. The basis for this is to make visible the 
totality of opioid use at all levels, patient, provider and facility, 
in order to identify high-risk situations. The Opioid Safety Initiative 
includes key clinical indicators such as the number of unique pharmacy 
patients dispensed an opioid, unique patients on long-term opioids who 
receive a urine drug screen, the number of patients receiving an opioid 
and a benzodiazepine (which puts them at a higher risk of adverse 
events) and the average dosage per day of opioids such as 
hydromorphone, methadone, morphine, oxycodone, and oxymorphone. 
Patients at risk for adverse events from use of opioids are identified 
through the use of administrative and clinical databases using pre-
determined parameters based on published evidence and expert opinion. 
Several aspects of the Opioid Safety Initiative were underway at the 
time of the October 10, 2013, hearing and have begun to bear positive 
results:

         Despite overall growth in the number of Veterans who 
        were dispensed any medication from a VA pharmacy, between the 
        quarter beginning in July 2012 compared to quarter ending in 
        December 2013, 33,142 fewer Veterans received any opioid 
        prescription (including short and long term use) from VA.
         Performing urine drug screens is a useful tool to 
        assist in the clinical management of patients receiving long-
        term opioid therapy. Between the quarter beginning in July 2012 
        compared to quarter ending in December 2013, the number of 
        patients on long term opioid therapy who have had at least one 
        urine drug screen increased by 27,783, while the total number 
        of patients on long term opioids decreased by 13,859.
         Whenever clinically feasible, the concomitant use of 
        opioid and benzodiazepine medications should be avoided. 
        Between the quarter beginning in July 2012 compared to quarter 
        ending in December 2013, 10,664 fewer patients were receiving 
        these drugs at the same time.
         Lastly, the average dose of selected opioids has begun 
        to decline slightly in VA, demonstrating that prescribing and 
        consumption behaviors are changing.

    These facts signal an important downward trend in VA's prescribing 
of opioids. VA expects this trend to continue as it renews its efforts 
to promote safe and effective pharmacologic and non-pharmacologic pain 
management therapies. Very effective programs yielding significant 
results have been identified, and are being studied as strong practice 
leaders.
    At the Tampa VA medical center, a safety-focused pain treatment 
program has been in place since 1988. The goal of the program is to 
replace the use of opioids for pain management with non-pharmacologic 
treatments such as behavior therapy, physical therapy, occupational 
therapy and/or kinesiotherapy. Tampa also has a long-standing process 
of identifying and conducting clinical reviews of Veterans who have 
received high morphine equivalent doses. At the Columbus, Ohio VA 
Outpatient Clinic, a Veteran-centered approach on opioid safety is 
focused on minimizing short acting opioids. This program has resulted 
in fewer Veterans on opioids with an 80 percent decrease in short 
acting opioid doses dispensed.

Current VA Pain Management Strategies

    Many Veterans require a combination of strategies for the effective 
management of pain, including treatment with opioid analgesics, which 
are known to be effective for at least partially relieving pain caused 
by many different medical conditions and injuries. VA treatment 
involves 1) interrupting or moderating the pain signal from peripheral 
disease/damage (e.g., medications/injections, transcutaneous electrical 
nerve stimulation (TENS), acupuncture, and stimulation.); 2) supporting 
structures (e.g., spine) to reduce activation of pain signals (physical 
therapy and exercise to build strength and flexibility and help control 
weight); and 3) help the Veteran cope with pain and learn better self-
management strategies (behavioral therapies).
    In 2010, the Department of Defense (DoD) and VA jointly published 
evidence-based Clinical Practice Guidelines (CPG) for the use of 
chronic opioid therapy in chronic pain available on the internet. 
Guidelines reserve the use of chronic opioids for patients with 
moderate to severe pain who have not responded to, or responded only 
partially to, clinically indicated evidence-based pain management 
strategies of lower risk, and who also may benefit from a trial of 
opioids. A toolkit has also been published and widely distributed to 
assist clinicians in using the Guidelines: (https://www/
qmo.amedd.army.mil and http://www.healthquality.va.gov). VA has also 
developed and disseminated a patient education resource, entitled 
``Taking Opioids Responsibly'', to increase Veterans' awareness of the 
risks and benefits of opioid treatment. More recently, the DoD-VA Pain 
Management Work Group (PMWG) of the VA-DoD Health Executive Council 
(HEC) has built upon the past work begun with the 2010 CPG and meets 
monthly to evaluate progress and improve effectiveness of projects 
focused upon the VA-DoD mission to improve pain management. These 
include two projects funded in 2013 and well underway: Joint Pain 
Education and Training Project (JPEP)'', and ``Tiered Acupuncture 
Training Across Clinical Settings (ATACS).''
    To support a system-wide approach, VA disseminated guidance and 
tools to providers to communicate long term opioid therapy 
expectations. Among the tools and guidance are:
    a. VA National Pain Management Strategy--VA has established pain 
management as a national priority. The objective of the strategy is a 
comprehensive, multicultural, integrated system-wide approach to pain 
management that reduces pain and suffering and improves quality of life 
for Veterans experiencing acute and chronic pain. The strategy 
incorporates care by pain medicine, behavioral health, physical 
medicine and rehabilitation and other specialty providers to manage 
complex patients.
    b. VHA Pain Management Directive--VA's Pain Management Directive 
defines and describes policy expectations and responsibilities for the 
overall National Pain Management Strategy and Stepped Care pain model.
    In coordination with DoD, a multi-modality, team-based, stepped 
care model is being implemented throughout VA. VA and DoD have 
developed patient and provider educational materials and two Joint 
Incentive Fund sponsored initiatives are underway.
    The Acupuncture Training Across Clinical Settings Project will 
create access to acupuncture for Veterans and Servicemembers in all 
clinical settings throughout VA and DoD.
    Forty-eight states have implemented Prescription Drug Monitoring 
Programs (PDMP) as a means to improve the quality of care and prevent 
the diversion of controlled substances. Two additional states and the 
District of Columbia have enacted legislation to develop a PDMP or have 
legislation pending. VA published an Interim Final Rule to allow 
participation in these programs and is successfully transmitting data 
from six pilot sites to state PDMPs. The remaining VA facilities are 
scheduled to begin transmitting data by the end of FY 2014.

Non-pharmacologic Approaches to Treatment of Veterans' Mental Health 
Problems and Pain Management

    The treatment of PTSD in VA follows the evidence-based 
recommendations of the Joint VA/DoD Clinical Practice Guideline for 
PTSD, most recently published in 2010 and accessible on the Internet at 
http://www.healthquality.va.gov/ptsd/. The first-line treatments for 
PTSD are evidence-based trauma focused psychotherapies such as 
Cognitive Processing Therapy (CPT) or Prolonged Exposure (PE) that have 
the highest level of evidence (Level A) indicating ``a strong 
recommendation that the intervention is always indicated and 
acceptable.''
    In terms of medications, the Guidelines strongly recommend (Level 
A) selective serotonin reuptake inhibitors or serotonin norepinephrine 
reuptake inhibitors. To date, VA has provided training in Cognitive 
Processing Therapy and/or Prolonged Exposure to more than 6,000 VA 
mental health staff. All VA medical centers provide at least one of 
these therapies, as required in VHA Handbook 1160.01, Uniform Mental 
Health Services in VA Medical Centers and Clinics. According to a 2011 
VA survey, 89 percent of VA facilities offered CAM treatments, an 
increase from 84 percent in 2002. The most common types of CAM provided 
are meditation (72 percent of VA hospitals); Stress Management/
Relaxation Therapy (66 percent); and Guided Imagery (58 percent); 
acupuncture (41 percent), and yoga (44 percent). The most common uses 
of CAM are for stress management, anxiety disorder, PTSD, depression, 
back pain, and wellness-promotion.
    The Acupuncture Training Across Clinical Settings Project is now in 
development to ensure, through standardized training of medical and 
battlefield acupuncturists, that all Veterans and Servicemembers in all 
clinical settings throughout VA and DoD have access to appropriate 
levels of acupuncture. VA has submitted a request for job 
classification to OPM for the hiring of certified acupuncturists.
    VA and DoD combined VA's Health and Information Group survey of CAM 
modalities with the RAND survey of DoD Innovative Mental Health 
Programs as the foundation for a joint registry that will provide a 
record of innovative treatment programs. The combined list now includes 
over 700 programs and is a substantial initial step toward 
characterizing and tracking innovative treatment modalities.

Conclusion

    As stated earlier, the Department of Veterans Affairs is committed 
to providing the highest quality care, which our Veterans have earned 
and deserve. Progress has been made regarding physician staffing and 
productivity standards, treatment for Veterans who experienced military 
sexual trauma, pain management programs, and procurement reform, and we 
will continue to seek improvement as we deliver high quality health 
care.
    We will continue to identify, mitigate, and prevent vulnerabilities 
within our health care system, wherever we find them, and we will 
continue to ensure accountability and develop a culture in which 
accountability principles are clearly stated. And when adverse events 
do occur, we will identify them, learn from them, improve our systems, 
and do all we can to prevent these incidents from happening again.
    Mr. Chairman, this concludes my testimony. I appreciate the 
Subcommittee's continued interest in the health and welfare of 
America's Veterans. At this time, my colleagues and I are prepared to 
answer your questions.

                                 [F-dash]

    March 20, 2014
    The Honorable Robert A. Petzel, M.D.
    Under Secretary for Health
    U.S. Department of Veterans Affairs
    810 Vermont Avenue, NW
    Washington, DC 20420

    Dear Dr. Petzel:

    Thank you for testifying at the February 26, 2014, Subcommittee on 
Health oversight hearing entitled, ``VA Accountability: Assessing 
Actions Taken in Response to Subcommittee Oversight.''
    As a follow-up to that hearing, I request that you respond to the 
attached questions and provide the requested materials in-full by no 
later than close of business on Friday, April 25, 2014.
    If you have any questions, please contact Christine Hill, Staff 
Director for the Subcommittee on Health, at 
[email protected] or by calling (202) 225-9154.
    Your timely response to this matter and your commitment to our 
nation's veterans are both very much appreciated.

    Sincerely,

    DAN BENISHEK M.D.
    Chairman

Questions for the Record From Chairman Dan Benishek M.D.,

    1. During the hearing, you stated that, `` . . . last year, VA 
removed 3,000 employees--approximately one percent of its workforce.'' 
Please provide the location, position, salary grade, and reason for 
dismissal for each of the 3,000 employees that the Department removed 
last year. Please also provide the number of employees that were 
resigned on threat of discipline last year.
    2. During questioning by Representative Wenstrup, you stated that 
the Department has conducted ``several'' studies comparing the cost of 
providing a given medical service through VA to the cost of providing 
the same service through either Medicare or the private sector. Please 
provide an electronic copy of such studies.
    3. Please provide a copy of the Information Bulletin that was 
distributed to Veterans Integrated Service Network (VISN) leadership in 
September 2013 regarding Military Sexual Trauma (MST) Coordinators and 
describe how the Department intends to measure and track the 
implementation, utilization, and effect of the Information Bulletin.
    4. Please describe how the Department intends to measure and track 
the implementation, utilization, and effect of the revised MST clinical 
reminder screening process. Is the Department on track to roll out the 
revised screening process by the end of fiscal year 2014?
    5. Please provide information regarding the number and location of 
any and all inpatient facilities or programs that exist specifically 
for the treatment of MST and whether such facilities or programs treat 
male veterans, female veterans, or both.
    6. Please describe the actions the Department is taking to expand 
access to care for male veterans who have experienced MST.
    7. Please provide a copy of the ``national educational resources'' 
referenced in the Department's written statement that have been 
``shifted to clarify the importance of creasing multiple opportunities 
for disclosure [of MST.'' What impact are these resources expected to 
have and how will such impact be tracked and measured?
    8. Please provide information regarding the pilot program that Mr. 
Matkovsky, VA's Assistant Deputy Under Secretary for Health for 
Administrative Operations, stated the Department was undergoing in VISN 
15 and VISN 23 to test an alternate procurement structure for certain 
high-cost medical equipment. Please include information regarding how 
the Department intends to measure the outcome of the pilot program.
    9. Is the Department still on track to complete the approximately 
909 outstanding delivery orders from 2012 by the end of April 2014? If 
now, why not and when will the outstanding delivery order be filled?
    10. Please describe how the Department intends to, `` . . . look at 
the consolidation process and change that as well.'' What changes are 
planned for VA's current consolidation process and what is the 
Department's timeline for full implementation of the planned changes?
    11. Please describe the actions that have been taken in the last 
year to respond to veteran and stakeholder concerns regarding the 
negative impact of changes to VA's prosthetic procurement process.
    12. Please list the ``incentive structures'' in the Patient 
Centered Community Care (PC3) program that Mr. Matkovsky mentioned in 
response to questions regarding PC3 reimbursement rates.
    13. What impact does the Department estimate full implementation of 
PC3 will have on VA's third-party collections?
    14. Please provide an update on the request for information (RFI) 
that the Department released to `` . . . identify commercial best 
practices for automation of health care billing systems . . . '' What 
response has the Department received to the RFI and how and when does 
the Department intend to incorporate those best practices into VA's 
third-party collections processes?
    15. Please list and briefly describe each of the ``many tools'' 
that Dr. Agarwal, VA's Deputy Under Secretary for Health for Policy and 
Services, testified had been developed to, `` . . . assist the local 
facilities in managing specialty [care] resources appropriately.'' 
Please also describe how the Department intends to track the 
implementation and utilization of these tools and measure the impact 
they have on veteran access to specialty care services.
    16. Please provide information regarding the ``comprehensive 
education and communication plan'' that is currently underway regarding 
specialty physician productivity and staffing standards.
    17. VHA Directive 2009-053, which provides pain management policy 
and implementation procedures, is scheduled to expire on October 31, 
2014. Please describe the Department's efforts to-date to prepare to 
update and reissue this directive and list any and all proposed policy 
or implementation changes that have been proposed.
    18. Please describe the role of the Opioid Safety Initiative within 
VA's existing pain management programs and provide information 
regarding how the Department intends to measure and track the 
Initiative's implementation, utilization, and impact.
    19. Please describe that actions, if any, that the Department has 
taken to ensure that pain management points of contact (POCs) within VA 
medical facilities regularly communicate with pain management 
specialists, as appropriate, about veteran patients experiencing acute 
or chronic pain. Please include any and all guidance that has been sent 
to the field regarding the referral process from pain management POCs 
to pain management specialists.
    20. During the Subcommittee's October 10, 2013, oversight hearing 
entitled, ``Between Peril and Promise: Facing the Dangers of VA's 
Skyrocketing Use of Prescription Painkillers to Treat Veterans,'' a VA 
witness testified about a VA-wide best practice in pain management 
called the ``Chronic Pain Rehabilitation Program.'' Please describe 
what efforts, if any, VA has taken to implement related or similar 
programs in other VA medical centers and clinics.
    21. Please describe the six ongoing pilot programs that are in 
place to test the Department's initiative regarding state prescription 
drug monitoring programs, to include information regarding how VA 
intends to measure the outcome of the pilot programs. Please also 
elaborate on the Information Technology ``limitations'' that were 
referenced in regard to the pilot programs.
    22. Please describe the actions, if any, that have been taken to 
make the VA formulary more consistent with the DoD formulary.

Questions for the Record From Hon. Keith Rothfus

    1. On September 9, 2013, you testified at a field hearing in 
Pittsburgh that VA would delay taking any administrative disciplinary 
action relating to the systemic failures and mismanagement at the VA 
Pittsburgh Healthcare System (VAPHS) that resulted in the deaths of at 
least six veterans due to an outbreak of legionella until the U.S. 
Justice Department concluded its criminal investigation. Then, on 
November 21, 2013, the Justice Department announced that it had 
concluded that investigation and that no criminal charges would be 
brought. It has now been over three months since that announcement, and 
the VA has yet to hold anyone at VAPHS accountable. Accordingly, please 
provide a detailed explanation of what VA has done internally to 
investigate those responsible for these preventable deaths, what VA has 
left to be done to conclude that investigation, and a date certain by 
which the families of the victims and Members of Congress can expect 
that the VA will take such administrative disciplinary action.
    2. On November 26, 2013, following the conclusion of the Justice 
Department's investigation into the legionella outbreak at VAPHS, 
Senator Pat Toomey and I sent a letter to Secretary Eric Shinseki 
requesting information about what administrative disciplinary action 
the VA planned to take, if any. To date, though, over three months 
later, neither Senator Toomey nor I have received any response. Can you 
please explain why the Secretary's office found it acceptable to not 
send any response to our inquiry? Is this indicative of how VA and the 
Secretary's office views Congressional inquiries and oversight 
generally?
    3. During the hearing on February 26, 2014, you stated that only 
one death resulted from the legionella outbreak at VAPHS. Yet, the 
Centers for Disease Control and Prevention (CDC) found in its 
investigation that at least 21 veterans were sickened as a result of 
the outbreak, five of whom died. Moreover, since the CDC released its 
report, a sixth veteran death has been connected to the outbreak as 
well. Accordingly, please provide a detailed explanation why VA has 
concluded, despite the findings of the CDC, that only one death 
resulted from the outbreak of legionella at VAPHS.
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT] 

           Letter From Robert A. Petzel to Hon. Dan Benishek
    March 13, 2014
    The Honorable Dan Benishek Chairman
    Subcommittee on Health Committee on Veterans' Affairs
    U.S. House of Representatives Washington, DC 20515

    Dear Mr. Chairman:

    I have reviewed the February 26, 2014, Committee on Veterans' 
Affairs, Subcommittee on Health hearing's unofficial transcript. I am 
writing to clarify responses I gave to questions during the hearing.
    First, let me state again that the Department of Veterans Affairs 
(VA) cares deeply for every Veteran we serve. Our goal is to provide 
the best quality, safe and effective health care our Veterans have 
earned and deserve. We take seriously any issue that occurs at any one 
of the more than 1,700 VA health care points of care across the 
country.
    I would like to clarify that I made an error when I stated the date 
of death of one of the patients occurred on July 12, 2012, at the VA 
Pittsburgh Healthcare System. The date of death was July 4, 2012. 
Further, of the six deaths discussed at the hearing, the Veterans 
Health Administration (VHA) is in possession of five death 
certificates. In the case of the sixth death, the Veteran passed away 
at a community hospital and VHA does not currently possess the death 
certificate. As previously reported, one death was attributed to 
Legionella pneumonia as the primary cause of death. I based my 
testimony on the immediate cause of death. However, there was a second 
patient who had a contributing cause of death listed as Legionella 
pneumonia on the death certificate, but it was not the primary cause of 
death. VA extends its condolences to the families of the Veterans 
affected by acquiring Legionella in our healthcare system.
    We are committed to doing whatever it takes to minimize the risk of 
Legionella and create the safest environment possible for our nation's 
Veterans to heal.
    Additionally, I would like to clarify a response I gave to a 
question on three deaths in Atlanta and the Office of the Inspector 
General (OIG) findings. There were two OIG reports on Atlanta, both 
published on April 17, 2013. The report titled ``Patient Care Issues 
and Contract Mental Program Mismanagement Atlanta VA Medical Center 
Decatur, Georgia'' (Report 12-02955-178) addresses two deaths that 
occurred under contract care; a report titled ``Mismanagement of 
Inpatient Mental Health Care Atlanta VA Medical Center Decatur, 
Georgia'' (Report 12-03869-179) addresses one death that occurred at 
the Atlanta VAMC. When I responded to the question regarding ``three 
deaths'' I was referring to deaths mentioned in Report 12-02955-178, 
not the death at the Atlanta VAMC Inpatient Mental Health Unit. It was 
my intent to say that the OIG report numbered 12-03869-179 did state 
that the staff's failure to watch patients may The Honorable Dan 
Benishek have contributed to the patient's death on the Atlanta VAMC 
Inpatient Mental Health Unit. VHA recognizes the significance of the 
tragic events that occurred in Atlanta and has taken action there to 
improve mental health services for Veterans. VHA's first priority is 
the delivery of high quality care to our Nation's Veterans including 
access to quality mental health care.
    I request that this letter be made an official part of the record. 
Thank you for your assistance.

    Sincerely,

    Julia Brownley,
    Ranking Member

                                 [F-dash]

                              DELIVERABLES
    Context of Inquiry: On February 26, 2014. Dr. Robert Petzel, Dr. 
Robert Jesse, Dr. Rajiv Jain, Dr. Madhulika Agarwal and Mr. Phillip 
Matkovsky testified before the HVAC-Health committee at a hearing 
titled: ``VA Accountability: Assessing Actions Taken in Response to 
Subcommittee Oversight''. There were seven deliverables from the 
hearing.
    Question 1:  Please provide the complete list of specialty care 
services that have not yet implemented productivity standards.

    Response: Specialties scheduled for implementation during the 3rd 
and 4th quarters this year:

     Cardiology
     Pulmonary/Critical Care
     General Surgery
     Physical Medicine and Rehab
     Anesthesiology
     Emergency Medicine
     Laboratory/Pathology
     Geriatrics

    Question 2:  Please provide an examination of the need for and 
potential incorporation of whistleblower protections for Veterans 
reporting military sexual trauma.

    Response: As noted by Committee Member Kuster, the Department of 
Defense is currently reforming policies regarding Servicemembers' 
protection against retaliation after reporting experiences of military 
sexual assault. VHA cannot conceive of a scenario where a parallel set 
of policies in VHA would be necessary.
         Disclosures of MST to a VA staff member would be 
        considered protected health information and thus subject to the 
        provisions of the Health Insurance Portability and 
        Accountability Act (HIPAA). Penalties for unauthorized use of 
        medical record information are already covered under HIPAA and 
        do not need to be duplicated by VA MST-specific whistleblower 
        protections.
         VA does provide care for some active duty 
        Servicemembers or Reservists who later return to active duty. 
        In these cases, VA medical record information may be shared 
        with the Department of Defense. If a disclosure of MST noted in 
        a Servicemember's medical record subsequently led to 
        retaliation against the Servicemember, the transgression would 
        presumably be covered under the Department of Defense's 
        whistleblower protections. Again, there is no need for a 
        parallel set of VA policies.
         Eligibility for VA care is independent of any 
        Department of Defense disciplinary or other proceedings, unless 
        the Veteran was to ultimately receive an Other Than Honorable 
        or Dishonorable discharge. If this discharge were the result of 
        retaliation, this would also presumably be covered by the 
        Department of Defense's whistleblower protections.

    Question 3:  The Circumstances surrounding the six members of the 
SES who had ``serious disciplinary actions'' taken against them over 
the last two years.

    Response: The Department is currently working to provide the 
circumstances surrounding the six members of the SES who has 
disciplinary actions taken and will provide this information as soon as 
possible.

    Question 4:  Provide a report on MST anonymous callers (Mystery 
Shopper).

    Response: The MST anonymous caller initiative targets a potential 
barrier to accessing MST-related care: difficulty contacting the MST 
Coordinator at a VHA health care facility. The initiative was first 
authorized in June 2010, and four rounds of review have been conducted 
since at an approximately yearly interval.

    During each round, two members of the MHS national MST Support 
Team--one female and one male--placed calls to the primary switchboard 
phone number of each facility during normal business hours. Following a 
standard script, callers asked for assistance in reaching the facility 
MST Coordinator. Calls were rated based on the ability of operators and 
other frontline staff (e.g., clinic clerks) to identify the MST 
Coordinator, the seamlessness of the transfer, and staff members' 
courtesy and sensitivity to callers' privacy concerns. Each facility 
was rated as Satisfactory, Marginal, or Unsatisfactory based on results 
from both calls. All facilities with a Marginal or Unsatisfactory 
rating received detailed feedback on the calls, and, to date, have 
submitted action plans to VA Central Office to address the identified 
issues negatively impacting MST Coordinator accessibility.
    The MST Support Team has taken several steps to assist facilities 
with preparing for the calls and with writing action plans. These 
include hosting a webinar presentation on the initiative, disseminating 
tip sheets of strategies on increasing and maintaining accessibility, 
and consulting with MST Coordinators to problem solve identified 
barriers.
    The initiative has been successful in improving nationwide MST 
Coordinator accessibility. In Round 4 (Aug-Sep 2013), 83.6% of 
facilities were judged to have Satisfactory accessibility, 13.6% 
Marginal, and 2.9% Unsatisfactory. These results represent a nearly 30 
percentage point improvement in Satisfactory accessibility and 16 
percentage point drop in Unsatisfactory accessibility since Round 1 
(Jul-Aug 2010).

    Question 5:  Provide the FY 2013 Office of Productivity and 
Efficiency's staffing standard report for MST (measuring the number of 
MST patients that VA facilities are treating and the staff resources 
available to treat them);

    Response: The Annual Report on Counseling and Treatment for 
Military Sexual Trauma (MST) for Fiscal Year (FY) 2013 is currently 
being reviewed and we will provide the report to you as soon as it is 
available.

    Question 5a:  Please also provide information paper on the .2 FTE 
for MST.

    Response: Please see below for the methods and results regarding 
decision to have .2 FTE for MST.

Methods

         The VA MHS MST Support Team completes an annual report 
        to determine the number of trained full time equivalent 
        employees (FTEEs) required to meet the mental health needs of 
        Veterans who have experienced MST, to fulfill the requirements 
        of 38 United States Code, Section 1720D(e). Because MST is 
        associated with a variety of mental health conditions and is 
        treated across multiple outpatient treatment settings, we could 
        not rely solely on the number of providers in a given mental 
        health service line or clinic. Therefore, we relied on methods 
        developed by the VA Office of Productivity, Efficiency, and 
        Staffing (OPES) to quantify workload associated with MST-
        related mental health care and calculate the effective number 
        of FTEEs associated with this care at each VA Health Care 
        System (HCS). From this we created a metric so that staffing 
        levels could be compared across facilities.
         Each VA HCS varies in the number of Veterans that it 
        serves who have experienced MST and therefore varies in the 
        demand for MST-related mental health care. To enable 
        comparisons across facilities, we calculated a ratio of 
        provider staffing against population size: the total FTEEs 
        providing MST-related mental health care for every 100 Veterans 
        with positive MST screens. It is important to note that not all 
        Veterans with a positive MST screen will want treatment and 
        among those that do request care, the amount of MST-related 
        care required by each Veteran will vary due to the range of 
        mental health conditions associated with MST. But in general, a 
        larger staffing ratio indicates greater staffing and 
        availability of MST-related mental health services.
         We examined the amount of MST-related mental health 
        care that each VA HCS provided and ranked facilities on two 
        indicators: 1) the proportion of Veterans with a positive MST 
        screen who received any MST-related mental health care; and 2) 
        the median number of visits among patients who received MST-
        related mental health care. We identified health care systems 
        that ranked in the top 25% for both indicators. We then used 
        staffing ratio data from these ``high volume'' VA health care 
        systems to establish the benchmark.
         The benchmark of 0.2 FTEE per 100 Veterans (or 2 FTEE 
        per 1,000 Veterans) who experienced MST is based on a 
        comparison with these ``high volume'' VA health care systems. 
        This benchmark is within two standard deviations of the average 
        staffing ratio at high volume health care systems. Even 
        staffing levels that are only a portion of a single FTEE 
        represent portions of workload from several different providers 
        due to the wide range of mental health conditions and clinic 
        settings associated with MST-related mental health care.

Results

         All VA health care systems provide MST-related care to 
        both female and male Veterans and all VA health care systems 
        have mental health providers knowledgeable in the treatment of 
        MST-related mental health conditions. In the most recent 
        analysis, 99 percent of VA health care systems were at or above 
        the established benchmark for MST-related mental health 
        staffing capacity. Over 64,000 Veterans received MST-related 
        mental health care from a VA health care facility. These 
        Veterans received a total of over 693,000 MST-related mental 
        health care visits from over 17,950 individual providers. Not 
        all of those 17,950 individual providers, however, spent all of 
        their clinical hours delivering MST-related mental health care. 
        The care delivered by those providers was equivalent to 580 
        FTEEs.
    Question 6:  Provide the committee with information about the VA 
employees that were held accountable for patient deaths at the Augusta 
VAMC and the Atlanta VAMC.
    Response: Disciplinary actions for Atlanta and Augusta are below:

Disciplinary Actions

Atlanta VAMC

          Chief of Staff--Reprimand
          Associate Director--Reprimand
          Associate Director/Nursing and Patient Care Services--
        Reprimand
          Chief, Mental Health Service Line--Reassigned
          Mental Health Inpatient Nurse Manager--Reprimand
          Associate Nurse Executive/Mental Health and Geriatrics--
        Reprimand
          Mental Health Inpatient Unit Medical Director--Admonishment
          Former Medical Center Director--Retired
          Veterans Integrated Service Network (VISN) Chief of Mental 
        Health Services--Retired

Augusta VAMC

          Chief of Staff-Received performance Counseling (Voluntarily 
        resigned from position)
    Question 7:  Please provide the timeline for VHA to contribute to 
the State Prescription Drug Monitoring Program?
    Response: VA participation with State Prescription Drug Monitoring 
Program is estimated to begin August 2014. This is predicated on a 
contract award by May 5, 2014, with a contract start shortly after 
award. The timeline includes achieving Milestone 2 (development enters 
implementation phase) by May 30, with code changes to other patches and 
Medication Order Checking Application (MOCHA 2.0) completed, 
documentation updated, and identification of additional test sites by 
the end of June. It is expected that this work would enter the national 
release process near the middle of July with testing and deployment 
leading to a mid-August completion. The State Drug Monitoring Program 
patch is dependent on MOCHA 2.0 which will deploy in waves between 
March 24, 2014 and June 16, 2014, as well as a titration management 
patch that will start simultaneously with the State Drug Monitoring 
Program patch. There are potential risks of delays to the August 2014 
start date that could arise from dependencies that include contract 
start date and unforeseen technical issues with states that are not 
part of the test site process. The VA Office of Information and 
Technology is responsible for oversight and management of software 
development and deployment for this program.

                                 [all]