[House Hearing, 114 Congress]
[From the U.S. Government Publishing Office]




 LEGISLATIVE HEARING ON DRAFT LEGISLATION TO IMPROVE THE AUTHORITY OF 
  THE SECRETARY OF VETERANS AFFAIRS TO HIRE AND RETAIN PHYSICIANS AND 
         OTHER EMPLOYEES OF THE DEPARTMENT OF VETERANS AFFAIRS

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

                             JOINT HEARING

                               before the

                         SUBCOMMITTEE ON HEALTH

                               joint with

                  SUBCOMMITTEE ON ECONOMIC OPPORTUNITY

                                 of the

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

                    ONE HUNDRED FOURTEENTH CONGRESS

                             SECOND SESSION

                               __________

                       WEDNESDAY, MARCH 16, 2016

                               __________

                           Serial No. 114-60

                               __________

       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               CORRINE BROWN, Florida, Ranking 
GUS M. BILIRAKIS, Florida, Vice-         Minority Member
    Chairman                         MARK TAKANO, California
DAVID P. ROE, Tennessee              JULIA BROWNLEY, California
DAN BENISHEK, Michigan               DINA TITUS, Nevada
TIM HUELSKAMP, Kansas                RAUL RUIZ, California
MIKE COFFMAN, Colorado               ANN M. KUSTER, New Hampshire
BRAD R. WENSTRUP, Ohio               BETO O'ROURKE, Texas
JACKIE WALORSKI, Indiana             KATHLEEN RICE, New York
RALPH ABRAHAM, Louisiana             TIMOTHY J. WALZ, Minnesota
LEE ZELDIN, New York                 JERRY McNERNEY, California
RYAN COSTELLO, Pennsylvania
AMATA COLEMAN RADEWAGEN, American 
    Samoa
MIKE BOST, Illinois
                       Jon Towers, Staff Director
                Don Phillips, Democratic Staff Director

                         SUBCOMMITTEE ON HEALTH

                    DAN BENISHEK, Michigan, Chairman

GUS M. BILIRAKIS, Florida            JULIA BROWNLEY, California, 
DAVID P. ROE, Tennessee                  Ranking Member
TIM HUELSKAMP, Kansas                MARK TAKANO, California
MIKE COFFMAN, Colorado               RAUL RUIZ, California
BRAD R. WENSTRUP, Ohio               ANN M. KUSTER, New Hampshire
RALPH ABRAHAM, Louisiana             BETO O'ROURKE, Texas

                  SUBCOMMITTEE ON ECONOMIC OPPORTUNITY

                     BRAD WENSTRUP, Ohio, Chairman

LEE ZELDIN, New York                 MARK TAKANO, California, Ranking 
AMATA RADEWAGEN, American Samoa          Member
RYAN COSTELLO, Pennsylvania          DINA TITUS, Nevada
MIKE BOST, Illinois                  KATHLEEN RICE, New York
                                     JERRY McNERNEY, California

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hearing records of the Committee on Veterans' Affairs are also 
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                            C O N T E N T S

                              ----------                              

                       Wednesday, March 16, 2016

                                                                   Page

Legislative Hearing On Draft Legislation To Improve The Authority 
  Of The Secretary Of Veterans Affairs To Hire And Retain 
  Physicians And Other Employees Of The Department Of Veterans 
  Affairs........................................................     1

                           OPENING STATEMENTS

Honorable Dan Benishek, Chairman, Subcommittee on Health.........     1
Honorable Brad R. Wenstrup, Chairman, Subcommittee on Economic 
  Opportunity....................................................     2
Honorable Julia Brownley, Ranking Member, Subcommittee on Health.     3
Honorable Mark Takano, Ranking Member, Subcommittee on Economic 
  Opportunity....................................................     3

                               WITNESSES

Max Stier, President and Chief Executive Officer, Partnership for 
  Public Service.................................................     4
    Prepared Statement...........................................    28
Roscoe G. Butler, Deputy Director of Health Care, National 
  Veterans Affairs and Rehabilitation Division, The American 
  Legion.........................................................     6
    Prepared Statement...........................................    36
Carlos Fuentes, Senior Legislative Associate, Veterans of Foreign 
  Wars of the United States......................................     8
    Prepared Statement...........................................    42
Carolyn Clancy, M.D., Deputy Under Secretary for Health for 
  Organizational Excellence, Veterans Health Administration, U.S. 
  Department of Veterans Affairs.................................     9
    Prepared Statement...........................................    44

        Accompanied by:

    Elias Hernandez, Chief Office, Workforce Management and 
        Consulting, Veterans Health Administration, U.S. 
        Department of Veterans Affairs

                       STATEMENTS FOR THE RECORD

American Federation of Government Employees......................    47
National Association of VA Physicians and Dentists...............    49
Veterans Affairs Physician Assistant Association.................    52
Nurses Organization of Veterans Affairs..........................    57
Merritt Hawkins..................................................    58
Paralyzed Veterans of America....................................    63
Disabled American Veterans.......................................    65
Iraq and Afghanistan Veterans of America.........................    68
Reserve Officers Association.....................................    69
American Podiatric Medical Association...........................    74
 
 LEGISLATIVE HEARING ON DRAFT LEGISLATION TO IMPROVE THE AUTHORITY OF 
  THE SECRETARY OF VETERANS AFFAIRS TO HIRE AND RETAIN PHYSICIANS AND 
         OTHER EMPLOYEES OF THE DEPARTMENT OF VETERANS AFFAIRS

                              ----------                              


                       Wednesday, March 16, 2016

             U.S. House of Representatives,
                    Committee on Veterans' Affairs,
                                    Subcommittee on Health,
                                                   Washington, D.C.
    The Subcommittees met, pursuant to notice, at 2:04 p.m., in 
Room 334, Cannon House Office Building, Hon. Dan Benishek 
[Chairman of the Committee] presiding.
    Present: Representatives Benishek, Wenstrup, Bilirakis, 
Zeldin, Roe, Costello, Huelskamp, Coffman, Bost, Abraham, 
Brownley, Takano, Ruiz, Titus, Kuster, O'Rourke, McNerney.

            OPENING STATEMENT CHAIRMAN DAN BENISHEK

    Mr. Benishek. Good afternoon. The Subcommittee will come to 
order. Welcome to today's joint Subcommittee on Health and 
Subcommittee on Economic Opportunity legislative hearing on 
draft legislation to improve the authority of the secretary of 
veterans affairs to hire and retaken physicians and other 
employees of the Department of Veterans Affairs.
    Thank you for all joining us here today. As I said before, 
providing a top-notch health care and benefits that our 
Nation's veterans deserve is impossible without an equally top-
notch workforce. VA's future depends on VA's ability to 
officially recruit and retain highly qualified and highly 
motivated professionals at all levels. Unfortunately, hiring 
remains a serious challenge across the department, a challenge 
that will only grow as VA's current staff gets older and 
increasingly eligible for retirement and the private sector and 
health care and benefits landscape gets increasingly 
competitive.
    The draft bill that we will be discussing this afternoon 
would simplify and shorten the VA's hiring process, strengthen 
VA's ability to bring the very best employees onboard, most 
importantly, ensure a robust workforce is available to serve 
our veterans for years to come, contains a number of VA 
legislative proposals that would improve the department's 
ability to recruit and fairly compensate key leaders and grant 
schedule flexibility for critical medical personnel.
    It also contains other important provisions that would, 
among other things, increase training for VA human resources 
employees, create a centralized recruiting database to assist 
in identifying interested applicants for vacant positions, 
eliminate compensation panels that would lengthen the hiring 
process for incoming physicians, and unnecessarily take 
existing providers away from direct patient care, and allow 
certain aspiring VA leaders to participate in an executive 
management fellowship program to gain valuable private sector 
experience that could be used to improve the VA's performance.
    I am grateful to be here today with Dr. Wenstrup, the 
Chairman of the Subcommittee on Economic Opportunity, to be 
working with him and other Members of our two Subcommittees on 
this very important issue. I thank you all for being here and 
now yield to Dr. Wenstrup for any opening statement he may 
have.

             OPENING STATEMENT OF BRAD R. WENSTRUP

    Mr. Wenstrup. Well, thank you, Dr. Benishek and good 
afternoon. And thank you to everyone with us here today.
    I look forward to our discussion today, as we have spent 
several months working on this proposal and listening to key 
stakeholders and holding a joint roundtable last December to 
begin the discussion on the language and to ensure we are doing 
this right.
    I know this Committee has focused heavily on accountability 
and while I think it is of the utmost importance, I think it is 
important that we also focus on the hiring and retention of 
high-quality employees within the department so that our 
veterans receive the best services possible.
    Last year, I made a commitment to several of our colleagues 
to also focus on improving the hiring process at VA, and I am 
excited about the work that has been done to package some 
common sense provisions together. I would note that this is 
still a draft bill. Let me just say that again, this is still a 
draft bill, and I look forward to the feedback that we will 
receive today so that we can make necessary changes to make the 
bill as close to perfect as possible.
    I do want to keep my comments short so we can get to our 
witnesses and their testimonies and questions, but before I 
yield back to Dr. Benishek, I do want to make a couple of 
comments about the testimony and views VA provided to us today, 
which I have to say are somewhat minimal at best, at this time.
    I am disappointed the department was unable to provide 
views or comment on a majority of the provisions that are in 
this bill. We want your opinion. And I understand that we only 
gave VA a couple weeks' notice about this hearing, and I know 
the OMB bureaucratic process is not known to be speedy, but 
this is not the first time the department has seen this bill or 
a version of this bill, as a draft was provided to the VA last 
November in preparation for our roundtable in December. So, I 
do hope to hear more from VA on these issues because we need 
your input.
    And with that, I yield back.
    Mr. Benishek. Thank you, Dr. Wenstrup.
    I will now yield to Ms. Brownley, Ranking Member of the 
Subcommittee on Health, for any opening statement she may have.

      OPENING STATEMENT OF JULIA BROWNLEY, RANKING MEMBER

    Ms. Brownley. Thank you, Mr. Chairman.
    And I want to thank you and Chairman Wenstrup for holding 
this hearing today. I would also like to thank the witnesses 
here today who have joined us to provide their expert views on 
the discussion draft we have before us.
    This draft legislation is another step forward in revising 
hiring practices at the Department of Veterans Affairs. As with 
any legislation, as Mr. Wenstrup said, we should make every 
attempt to scrutinize the provisions and understand the 
unintended consequences that may arise from good intentions 
contained in the bill.
    This draft includes my common sense provisions including 
setting competitive pay levels for medical center and network 
directors and ensuring that emergency room doctors and staff 
have the scheduling flexibility needed to provide quality 
services when they are needed. I support the effort to 
institute competitive pay for VA medical center directors. The 
West Los Angeles VA Medical Center, which serves my veterans in 
my county, in Ventura County, recently hired its first 
permanent director in more than two years. I believe that 
making medical center directors' salaries more comparable with 
market rates would go a long way towards attracting and keeping 
the most-qualified candidates and filling the leadership vacuum 
that exists in many of the veteran-integrated service networks.
    I appreciate the concerns many of the witnesses have 
brought to your attention in their submitted testimony. I also 
have some concerns about the draft bill. In particular, I hope 
that we can work to come to an agreement, particularly, on 
Section 9 which modifies the existing veterans hiring 
preference. I would like to understand the pros and cons of 
this section better so as we move forward, we are not putting 
the VA at a disadvantage when competing for executive talent 
with other agencies in the private sector.
    I look forward to hearing from our guests today on their 
thoughts on improving the system, and, again, I thank both the 
Chairmans for calling this hearing.
    Mr. Benishek. Thank you very much.
    I will now yield to Mr. Takano, the Ranking Member of the 
Subcommittee on Economic Opportunity, for any opening statement 
that he may have. Mr. Takano?

                OPENING STATEMENT OF MARK TAKANO

    Mr. Takano. Thank you to both Chairmen for holding this 
hearing. Thank you, Chairman Benishek.
    Over the past three years, the Veterans' Affairs Committee 
has worked hard to reform the VA, particularly, as it involves 
the discovery of health care by the Veterans Health 
Administration. During this time, we have focused much of our 
discussion and our disagreements on how easy we should make it 
for the VA to fire employees. We have also focused on the 
important role of VA whistleblowers and how we can best protect 
them from retaliation.
    Today, we have the opportunity to discuss another important 
element of employment at the VA, a draft bill that seeks to 
improve VA's ability to attract, hire, and retain the best 
employees and providers. The draft legislation is a good 
starting point. I am encouraged by common sense solutions such 
as granting VA providers to work more or less 80 hours per bi-
weekly work period. I want to thank my colleague Dr. Ruiz for 
introducing this idea. I just thanked you, Dr. Ruiz.
    I also support--you had a great idea with this 80 hours per 
bi-weekly work period--I also strongly support incentivizing 
more student veterans to pursue graduate medical education 
programs in mental health fields, and hope we can do more to 
encourage graduates to work at the VA.
    I want to ensure we do not dilute Veterans' Preference or 
cut out valuable H.R. procedures for the sake of efficiency, 
but today I plan to listen to the hopefully robust discussion 
on these sensitive topics.
    So, again, I thank the Chairmen for bringing this bill to 
us to discuss and improve before it is introduced.
    Thank you also to the VSOs, the VA, and other 
representatives who have come to join in this discussion. I 
look forward to hearing how we can help VA improve its hiring 
policies.
    Thank you, and I yield back, Mr. Chairman.
    Mr. Benishek. Thank you, Mr. Takano.
    Joining us on our first and only panel is Max Stier, the 
President and Chief Executive Officer of the Partnership for 
Public Service; Mr. Roscoe Butler, the Deputy Director of 
Health Care for the National Veterans Affairs and 
Rehabilitation Division of The American Legion; Carlos Fuentes, 
the Senior Legislative Associate for the Veterans of Foreign 
Wars of the United States; and Dr. Carolyn Clancy, the Deputy 
Under Secretary for Health for Organizational Excellence for 
the Veterans Health Administration of the U.S. Department of 
Veterans Affairs; accompanied by Elias Hernandez, the Chief 
Officer for Workforce Management and Consulting.
    Thank you all for being here this afternoon. Mr. Stier, we 
will begin with you. Please proceed with your testimony. You 
have five minutes.

                     STATEMENT OF MAX STIER

    Mr. Stier. Thank you very much for holding this hearing and 
for the work you have done here.
    The problems you are addressing are problems that face the 
entire government, but I would say that you are the best 
Committee on trying to address them, so kudos to you. Also, I 
wanted to thank you for the great work you have done with your 
own staff, because they have been exceptional to work with, and 
that is critical for you, for the legislation, and bluntly, for 
the country.
    This is an incredibly important issue. Three facts that 
stand out to--one of them is the limited demographic diversity 
that exists at the VA. In 2015, it was only two-thirds of 1 
percent of VA's workforce was under the age of 25. So, think 
about that, two-thirds of 1 percent, and only 5.35 percent were 
under the age of 30. So that is one devastating fact. Second, 
only around a half of 1 percent of new hires since 2012 have 
been under the Pathways Program, which is the primary way that 
agencies are supposed to be hiring either student interns or 
recent college graduates. The third devastating fact is a 
recent study that showed that ratings of government agencies on 
the statement, ``My agency is unable to recruit the best 
employees,'' should VA and its components were at or near the 
top. That is the backdrop that you are seeing here. It is so 
important.
    I have three areas, where I think you are really doing 
important work on this bill. One involves the talent itself. A 
couple of things that are powerful and you have heard in some 
of the opening statements that you made, supporting market pay 
for your medical directors, is very important. You are not 
going to get the talent that you need in that area unless you 
do that.
    We would argue at the Partnership that the pay system, more 
generally, in the Federal workforce is broken. It was built in 
1949. It was about internal equity when you had a clerical 
workforce. The whole thing should be based on market 
compensation in a world in which that is the way we have to 
compete for talent. That may mean some folks are paid more, 
some folks less, but that is the right way to do it. But you 
are going in the right direction with that.
    Secondly, you improve the Pathways Program, which brings 
student interns and new college graduates in--in very important 
ways. That is going to be very important to do. One thing I 
would add is you have to encourage the VA to actually use the 
authority--and I will come back to this--the legislation is a 
starter pistol; it is not at the end of the day. You have given 
them tools, but I hope you will do oversight to make sure that 
they use that authority you are providing them.
    On data, you can't manage what you don't measure. I think 
in this bill you are requiring a number of data points to be 
collected around hiring effectiveness. It will give you real 
insight into whether VA is doing its job well, and that is 
critically important.
    And then on leadership accountability, the idea of holding 
the political appointees to the same standards as career 
leaders is absolutely essential. Across government, you have 
political appointees, 4,000 of them. Few are in VA, but you 
still don't have the normal line of sight for the career people 
that stacks up their performance plans against the objectives 
of the organization which starts with the leadership. You need 
clarity about what they are trying to achieve, how they are 
being held accountable, and then it cascades into the rest of 
the organization. That is really important.
    Three things that I think you could do better with this 
bill. One, for the passport idea, it seems to me that the re-
employment of former employees is extremely important. Right 
now, the authority allows for only a one grade increase. I 
would suggest that that is an unnecessary restriction. If 
someone spends time in the VA or some other agency, which is 
the other piece of this, they ought to be able to come back if 
they have developed skills that they can then bring back to the 
organization more than just one grade up.
    Secondly, I am troubled by the expansion of Veterans' 
Preference to the SES. Veterans' Preference is incredibly 
important. However, in the context of what the VA is dealing 
with right now with its SES, it is a troubled place. They can't 
recruit people right now. This is not the time to make it more 
difficult. There are other things that could be done that I 
think would be more powerful and less concerning.
    And, third, on the executive management fellowship program, 
the cap needs to be raised from 30. Right now you have over 
7,000, by our account, eligible participants; 30 just doesn't 
make any real difference. The question has arisen, well, if you 
got a challenge for getting talent in, do you really want to 
send your people out? The answer is yes. You want to grow and 
develop your people. You will retain your talent better if you 
do it, and, bluntly, we think it should be a two-way program, 
so you can bring folks from the private sector in and that will 
also help you get great talent and refresh the workforce, which 
is so important.
    The so last issue is: this is not just about the 
legislation, as I mentioned; it is about the enablers--your 
oversight is going to be absolutely essential to ensure that 
the VA is doing the work that it needs to do and these 
provisions are funded.
    Happy to answers questions. That is as fast as I can talk. 
Thank you.
    Mr. Benishek. Good job, Mr. Stier, in talking fast.
    Mr. Stier. I should say I am Stier and it is pronounced--
    Mr. Benishek. Stier.
    Mr. Stier [continued]. --you know, if you look at it, it 
looks like Stier. Anyone who says Stier, ordinarily, you are 
like, you don't know how to pronounce words, but parents decide 
pronunciation, so what can I do? So, it is Stier.
    Mr. Benishek. Yeah. No, no, no, that is fine. Great. 
Perfect. Thank you very much.
    Mr. Stier. Thank you.

    [The prepared statement of Max Stier appears in the 
Appendix]

    Mr. Benishek. Mr. Butler, I will recognize you now for five 
minutes.

                 STATEMENT OF ROSCOE G. BUTLER

    Mr. Butler. Thank you. For nearly two decades, The American 
Legion has been expressing concerns about staffing shortages 
for physicians and medical specialists in the VA. We've seen 
this because we have been there as part of our ongoing System 
Worth Saving task force visits that evaluate VA health care in 
every VISN, from rural to urban, and we have tried to make sure 
VA is fully staffed to provide high-quality, efficient care to 
meet the needs of local veterans.
    Chairman Benishek, Wenstrup, Ranking Member Brownley, 
Takano, and distinguished Members of the Subcommittee on Health 
and Economic Opportunity, on behalf of National Commander Dale 
Barnett and The American Legion, and the country's largest 
patriotic wartime service organization for veterans, comprising 
over two million members and serving every man and woman who 
have served, and worn the uniform for this country, we thank 
you for the opportunity to testify regarding the draft 
legislation regarding improving the authority for the Secretary 
of Veterans Affairs to hire and retain physicians and other 
employees of the department.
    As reflected in our written testimony and through the eyes 
of The American Legion's System Worth Saving Program, which I 
frequently participate in, we have tracked and reported 
staffing shortages at every VA health care system across the 
country. We see the staffing shortages throughout the VA, and 
we feel it is getting worse, and not improving. The American 
Legion's System Worth Saving 2014 executive summary found that 
several VA medical centers continue to struggle to fill 
critical leadership positions across multiple departments.
    These gaps have caused communication breakdowns between 
medical center leadership and staff that works within these 
departments; therefore, for the reason outlined in our written 
testimony, The American Legion fully supports Sections 2, 3, 4, 
5, 8, 9, 11, 14, and 15 of the draft legislation to improve 
hiring practices at the Department of Veterans Affairs.
    However, Section 7 gives us great concerns. As it currently 
stands, VA has over half of their critical leadership positions 
either unfilled or filled by individuals on an interim basis. 
Sending a portion of the workforce out of VA every year would 
only exacerbate this situation. If VA can afford to lose those 
personnel for even a year, then we believe the VA may not need 
those positions to be filled.
    The American Legion would rather see the VA fill the 
positions and ensure there is a full workforce available to 
treat the needs of veterans, therefore, for this reason, The 
American Legion opposes Section 7, which would create within 
VA, an executive management fellowship program.
    There are plenty of other sections of this legislation that 
offers improvements to VA health care. Section 3 offers a fix 
to a problem The American Legion has long sought a solution to, 
adjusting Federal work guidelines to fix the unusual hours 
necessary to staff emergency rooms.
    Other sections address fixes to how VA determines market 
values to stay competitive for health care and hiring, how VA 
evaluates which portions are needed, and attempt to further 
refine the accountability process for VA employees. Any of 
these measures should contribute immeasurably toward improving 
VA and these are measures that should move forward with the 
passage of this legislation.
    Again, on behalf of our national commander, Dale Barnett, 
and the millions of dedicated veterans that comprise the 
Nation's largest veterans' service organization, we thank you 
for having the opportunity to speak today. I would be happy to 
answer any of the Committee's questions, and, again, thank you.
    Mr. Benishek. Thank you very much, Mr. Butler.

    [The prepared statement of Roscoe G. Butler appears in the 
Appendix]

    Mr. Benishek. Mr. Fuentes, you are now recognized for five 
minutes.

                  STATEMENT OF CARLOS FUENTES

    Mr. Fuentes. On behalf of the men and women of the VFW and 
our auxiliaries, I would like to thank you for the opportunity 
to present our views on ways VA can improve retirement--I'm 
sorry--recruitment, retention of high-quality health care 
professionals and other employees.
    The VFW thanks you for recognizing that VA's ability to 
hire and retain high-quality employees is equally as important 
as its ability to fire and demote employees who put veterans at 
risk. The VFW agrees with many of the ideas included in the 
draft legislation being discussed today, however, we would like 
to share an idea that we hope the Subcommittees will consider.
    During our site visits of VA medical facilities, the VFW 
has noticed one constant struggle: hiring and retaining entry-
level clerks who help with answering phones, greeting patients, 
scheduling appointments, and other administrative tasks. During 
our visits, we often hear from providers and facility 
leadership say that the lack of administrative support limits 
their ability to deliver health care to veterans. This issue 
must be addressed, authorizing VA to quickly fill high-turnover 
positions at VA medical facilities.
    Similar to VA medical facilities, the VA Canteen Service 
relies on entry-level employees to operate and maintain its 
services; however, the Canteen Service is exempt from certain 
Title V competitive service requirements to ensure high 
turnover does not impact its ability to operate retail stores, 
cafes, and other quality-of-life programs in VA medical 
facilities around the country. The VFW urges Congress to 
consider extending these authorities to VHA to quickly fill 
high-turnover vacancies.
    The VFW supports most sections of the discussion draft 
being considered today, which takes a multifaceted approach 
towards expanding VA's authorities to hire and retain high-
quality employees.
    In the interest of time, I would like to comment on two 
sections we believe can be improved. The VFW opposes Section 4, 
which would expand VA's Yellow Ribbon Program to require VA to 
help veterans cover the costs of advanced degrees in mental 
health. The VFW supports efforts to provide additional 
assistance for veterans who choose to advance their careers and 
assist their fellow veterans by obtaining advanced degrees in 
mental health; however, we do not believe that amending the 
Yellow Ribbon Program is the best option to do so.
    The Yellow Ribbon Program was established to supplement the 
Post-9/11 G.I. Bill by authorizing VA to enter into agreements 
with educational institutions to cover up to 50 percent of the 
gap between the costs of tuition and fees associated with 
degree programs and the statutory caps.
    The VFW is concerned that this legislation fails to ensure 
veterans have enough Post-9/11 G.I. Bill eligibility to 
complete their advanced degrees in mental health. For example, 
veterans who use their Post-9/11 G.I. Bill to obtain a 
bachelor's degree and would like to participate in this 
program, are unlikely to have enough eligibility remaining to 
complete an advanced degree in mental health. The VFW is a 
strong proponent of public-private partnerships, but believes 
that the program would be better suited under VA's Health 
Professionals Education Assistance Program.
    Section 9 would require VA to comply with certain Title V 
competitive service requirements when hiring SES employees. 
While the VFW supports applying Veterans' Preference when 
hiring VA SES employees, we feel that Congress must streamline, 
not impede, VA's ability to hire qualified executives. That is 
why we recommend that the Subcommittees exempt VA SES 
employment process from Title V competitive service 
requirements.
    To ensure VA hires qualified veteran senior executives, 
Congress should require VA to properly consider veterans when 
considering SES employees, regardless of which authority or 
hiring authority they use.
    Mr. Chairman, this concludes my testimony. I would be happy 
to answer any questions you may have.
    Mr. Benishek. Thank you, Mr. Fuentes.

    [The prepared statement of Carlos Fuentes appears in the 
Appendix]

    Mr. Benishek. Dr. Clancy, you may proceed with your 
testimony.

               STATEMENT OF CAROLYN CLANCY, M.D.

    Dr. Clancy. Good afternoon, Chairman Benishek, Chairman 
Wenstrup, Ranking Member Brownley, Ranking Member Takano, and 
Members of the Committee. Thank you for inviting us here today 
to present our views on the draft bill to improve the authority 
of the secretary of veterans affairs to hire and retain 
physicians and other employees.
    Joining me today is Elias Hernandez, the Chief Officer for 
Workforce Management and Consulting; Tia Butler, who is sitting 
behind me, the Executive Director of the Corporate Senior 
Executive Management Office; and Kimberly McLeod, Associate 
Chief Counsel.
    First, we want to thank the Subcommittees for including 
three of our legislative proposals in the draft legislation. 
These will give us the necessary resources to meet the 
department's obligation to meet--to provide timely quality 
health care and benefits to our veterans. We are happy to 
support several sections of the proposed bill, including 
Section 2, which matches a proposal put forward last year in 
VA's 2017 budget submission.
    VA believes that there are primary factors that warrant a 
separate compensation system for medical center directors and 
VISN or network directors, which are detailed in the written 
testimony. VA requests, however, that the section stating that 
medical center director and network directors be a qualified 
doctor of any kind, be removed from the bill.
    It is already difficult to recruit for these positions and 
this additional restriction would make it nearly impossible for 
recruit in some areas; moreover, running a hospital is an 
inherently complex skill set requiring a diverse background, 
including skills needed to manage from multimillion-dollar 
budget facility and staffing operations and so forth. 
Physicians may or may not have these skills and there are other 
graduate programs that do give people this kind of training; in 
fact, we have a fellowship program for people who graduate from 
master's of health administration programs.
    Section 3 of the proposed bill would allow VA to arrange 
flexible physician and physician assistant work schedules to 
allow for the hiring and full implementation of a hospitalist 
physician system and to accommodate the unusual work schedule 
requirements for emergency medicine physicians--thank you, Dr. 
Ruiz--VA supports this increased flexibility for critical 
medical personnel.
    Hospitalists and emergency medicine physicians specialize 
in the care of patients in the hospital, often working 
irregular work schedules to accommodate the need for efficient 
hospital care. And we believe that increased scheduling 
flexibility would align our practices with the private sectors, 
which would facilitate the recruitment and retention of 
emergency physicians as well as the operation of the 
hospitalist physician system at all VA medical centers.
    Section 4 of the bill would amend Title 38 to prohibit the 
use of transferred entitlement under the public-private 
contributions. VA supports legislation that would provide 
training and employment opportunities for veterans, however, 
the department has some concerns with this section of the bill. 
VA is not certain a change in the way VA and institutions of 
higher learning share contributions for specific degrees and 
programs would be beneficial.
    Under its current structure, the Yellow Ribbon Program is a 
remarkably successful program with nearly 2,000 participating 
institutions. For VA to support this bill, each of the 
professions listed that has educational and licensure 
requirements would need to have a corresponding provision that 
would state that the program meets the educational requirements 
defined by VA's qualification standards.
    As for the report required in Section 5, we defer to the 
Office of Inspector General on how they would process this 
report.
    VA supports Section 6, which would eliminate the 
compensation panel recommendation process. This section is also 
similar to another proposal put forward in February 2016 in 
VA's 2017 budget submission. The compensation panel process is 
time-consuming and adds little value as medical center 
directors and other approving officials already have the final 
authority to approve the rate of pay. This process also 
contributes to a delay in hiring, which is probably our 
greatest concern. It would be more cost-effective and efficient 
to allow a selecting official and to recommend the appropriate 
salary for prospective employees and eliminate this 
compensation panel process.
    We very much look forward to working with the Committees 
and our agency partners to finalize language on these 
provisions. The remaining sections will be discussed in a 
follow-up views letter that is currently being drafted and we 
will forward these remaining views and costs to you 
expeditiously.
    Thank you, Mr. Chairman for this opportunity to present our 
views on this draft bill, and my colleagues and I are happy to 
respond to any questions that you or other Members might have.
    Mr. Benishek. Thank you, Dr. Clancy. I really appreciate 
your answers there.

    [The prepared statement of Carolyn Clancy, M.D. appears in 
the Appendix]

    Mr. Benishek. I yield myself five minutes for questions. 
And, frankly, I was kind of excited to have this hearing 
because it is a lot of important issues. I think the roundtable 
really got us a lot of input and this is basically the next 
step.
    Dr. Clancy, I agree with you that this compensation panel 
doesn't make a lot of sense to me because, a physician who is 
about to be hired is going to surely shop around to see what 
other people are offering and that doesn't make sense--but what 
I would like to know is, what else can we do besides this, to 
speed up the process? I have heard that it takes up to a year 
to hire somebody, physicians in particular, at the VA, so 
besides a central database for finding people looking for work 
and this process here, what other processes could we do? And 
maybe Mr. Stier would like to comment on that, too.
    So, let's start with Mr. Stier, and I will give you an 
opportunity, too, Dr. Clancy. Mr. Stier, what else should we be 
doing to make this process quicker?
    Mr. Stier. Well, part of it, which you already have in the 
bill, is that it is going to be really important to have good 
information. My bet is that there is a high degree of 
variability across the system as to who is hiring fast and who 
is not, and what the experience is like for the potential 
applicants to the positions.
    And so, collecting information about who is actually doing 
hiring well and making data available across the whole network 
of VA facilities, I think will help you identify the best 
practices that ought to be adopted more generally.
    What you are doing here, I think is very important, but I 
really do believe it is just the starter's pistol and at the 
end of the day, ensuring that these authorities are used 
effectively, that the execution of the tasks that you are 
trying to facilitate happen effectively, is most important.
    Mr. Benishek. To be measured as they go.
    Mr. Stier. Correct. They need to be measured and they need 
to identify, again, where certain components are doing it well 
so that they become the model for best practices across the 
whole organization.
    I am confident that if you explored, you used a year 
figure, you would find organizations within the VA system that 
are actually doing it really, really well, best-in-class. The 
question is, what are they doing and why isn't everyone else 
doing it, and how do you get them to do that?
    Mr. Benishek. Dr. Clancy, let me ask you in follow-up of 
what Mr. Stier was saying, do people who are interviewed for 
positions, are they given an opportunity to comment on the 
process? Do you collect that data at all?
    Dr. Clancy. We collect exit-interview data when people 
leave. I am not sure about the front-end.
    Mr. Benishek. But when hiring, do you interview the people 
that you are hiring to comment on the process--
    Dr. Clancy. Mr. Hernandez?
    Mr. Benishek [continued]. --perhaps in an anonymous way, so 
that they can give comments on the process?
    Mr. Hernandez. Yes, Mr. Chairman, we do collect information 
in terms of the interview process, however, that information is 
obviously not released to anyone, other than the hiring 
official.
    But what I would like to say is, I fully agree with 
everything that has been said here today, and I would like to 
share some information regarding, you know, some of the 
improvements we have made in the hiring process, in particular, 
for the positions of nurses. And this bill that is being 
introduced is also going to help us do even better in the 
hiring process.
    We do track the hiring process in terms of the speed of 
hire, and we have a measure in the organization where all the 
hiring actions must occur within 60 days. Eighty percent of 
those actions must occur within 60 days.
    The recent data that we collected, you know, in fiscal year 
2015, and so far this year--
    Mr. Benishek. I guess I don't understand though, it is 60 
days? You are saying the hiring process is 60 days? That is 
contrary to most of the information that I have ever heard. 
Most of the time, people tell me it takes months.
    Mr. Hernandez. Yes, Mr. Chairman, that is what I--you know, 
if I may, that is what I am trying to convey, that we still 
have issues, and I will tell you what those issues are shortly.
    So we collect the data and we measure the hiring process 
and the different stages of the process, and right now, we are 
about 78 percent of all the hires that have taken place in 
fiscal year 2015 have been met within 60 days; however, that 
measure only measures from the beginning of the process to a 
tentative job offer, okay.
    What happens after the tentative job offer is the 
information that we are really keying in, as an example, the 
physicians, we can give them a tentative job offer based on the 
data that we collected within 96 days; however, it takes an 
additional 32 days to bring them onboard.
    So there are a lot of factors associated with that in terms 
of, you know, the scope of practice, them being able to kind of 
close their scope of practice in the previous organization 
going into the new organization, and also the credentialing 
process, which, by the way, VHA has made major improvements to 
that area where we are right now averaging about 35 days for 
some of those credentialing processes, which is a whole lot 
better than what it is in the private sector of 45 days.
    The challenges that we have--
    Mr. Benishek. I guess that sounds like really great 
numbers, but that is just not the way it is from what I have 
been talking to people, okay. I talk to people and that is just 
not the numbers that you submit here; 60 days and 90 days is 
not it.
    But I am out of time and I am going to yield to Dr. 
Wenstrup.
    Mr. Wenstrup. Thank you, Mr. Chairman.
    Mr. Butler, the American Legion's written statement 
mentioned some of the challenges the VA faces attempting to 
recruit and retain medical staff in rural areas, and I know 
that is difficult in parts of my district as well.
    But do you believe that this bill that we are considering 
could improve the recruitment and retention in rural areas? And 
if it is not able to, what would you suggest maybe that we add 
to the bill to try and improve that?
    Mr. Butler. Well, I think there are good components, 
excellent components within the bill that will enhance VA's 
existing hiring authority and give facility leadership the 
ability to hire employees more quickly.
    I was out on a recent visit in Reno, Nevada and, in 
response to the Chairman's question, what I heard, there are 
certain hard-to-fill positions, audiologists, and it is taking 
years to fill those positions, not necessarily because--well, 
because they don't have the locations and the disciplines, the 
teaching facilities, they don't have the source where people 
are interested in coming to like Nevada for those positions, 
and then they are competing with private industry.
    So I think that you have to build a program that is on the 
same level that the private industry program is, and it has the 
same or similar metrics, so that it is more attractive to 
outside providers when they are considering the VA. If they 
look at the outside community hospital versus the VA, it is 
much easier for them, higher pay and other things that drive 
them, that they will choose the community hospital over the VA.
    And I think from what we are seeing, that it takes a 
special breed of doctor to work for the VA. They really have to 
be committed, and have to care, have that mentality of caring 
for veterans and not all doctors, I would say, have that same 
mentality. Some people's drivers is the money that they would 
make, but I think the doctors that really choose to work for 
the VA choose it for different reasons other than money.
    And so I think that you have to take all of those factors 
into consideration and then build a program that is much more 
competitive with the private community.
    Mr. Wenstrup. Thank you.
    Dr. Clancy, on that same vein, are there barriers that 
Congress could break down to make it easier in the rural 
communities for recruitment and retention?
    Dr. Clancy. So I appreciate my colleague's comments very 
much from the American Legion. I will say, I think all of U.S. 
health care is struggling with how do you get people to come to 
rural areas. In fact, I saw something recently, I didn't see 
the backup detail, you know, that claimed that physicians with 
higher educated specialties were harder to recruit to rural 
areas.
    If there is one area where our system would have a bit of a 
barrier and I am at a loss for how you all could help, although 
I would be happy to be surprised, a private sector hospital 
could actually be helping for the spouse to get a position, 
other opportunities and so forth, and that we are hiring for 
that one position, right? So that is about the only thing I can 
think that would be helpful.
    It is very clear to us that expanding our footprint in 
telehealth and other kinds of virtual care is going to be 
hugely important to our efforts in rural areas, but happy to 
work with you on other ideas.
    Mr. Wenstrup. Well, one thought that I have in that vein 
is, you know, you are talking about small communities are 
having the same problem, same problem that VA is having. I 
mean, if both entities are looking for one type of specialist, 
there should be ways to start thinking about collaborating--
    Dr. Clancy. I think that is a great idea.
    Mr. Wenstrup. --to bring a specialty to the area.
    With that, I yield back.
    Mr. Benishek. Ms. Brownley, you are recognized.
    Ms. Brownley. Thank you, Mr. Chairman.
    I think just following up a little bit on this line of 
questioning, I just had a general question and would appreciate 
a short answer, if it is possible. But if we get to the 
consolidation of non-VA care and that program, how would that 
affect really the number of employees needed for veterans' 
health care within the VA, if that makes sense?
    Dr. Clancy. It makes perfect sense. I am very optimistic 
that we will indeed, with your help, get to consolidation of 
all paths to community care. And I think the answer to your 
question is going to depend on the part of the country that you 
are talking about, and the issue is going to be less about 
numbers of VA physicians, and more about the distribution by 
specialty. But I don't believe that we have got a very clear-
cut analysis, but we would be happy to get back to you with 
more information.
    Ms. Brownley. Do you intend on doing some kind of analysis? 
Because I think it would be helpful in terms of what we are 
looking at here, I think it would also be helpful in terms of 
moving forward, in terms of good selling points, if you will, 
towards consolidation of these programs, which I think is 
important.
    Dr. Clancy. I don't know actually if it is on the list yet, 
but it is now.
    Ms. Brownley. Okay.
    Dr. Clancy. And obviously making that consolidation and 
integration happen is going to be key, but I am happy to take 
that back.
    Ms. Brownley. Okay. You know, we have just kind of gone 
through really, as I mentioned in my opening remarks, a two-
year space of time where we haven't had a permanent director of 
the West L.A. Medical Center. We finally do now, we are very 
happy that we do--
    Dr. Clancy. We are too.
    Ms. Brownley [continued]. --but it is--has been a long 
road.
    And so I just wanted you to comment a little bit on 
succession plans and how they are being conducted at the VA, 
and are they being conducted, you know, across services and 
across the country?
    Dr. Clancy. It is a standing practice that our facilities 
and our networks actually have a regular cycle of succession 
planning. As Mr. Stier alluded to earlier, I am quite confident 
that there is some variability. I haven't taken a very close 
eye on all of those, but that has long been a standard practice 
for all of our facilities.
    Ms. Brownley. You are sure that it is a standard practice 
across the country--
    Dr. Clancy. Yes.
    Ms. Brownley [continued]. --across centers?
    Dr. Clancy. No, the extent to which the crisis and many of 
our vacancies have, you know, cut that off or interrupted it in 
the recent past year or two, I don't know, but I would be happy 
to have someone take a look at that and get back to you.
    But I will tell you, people take this very, very seriously.
    Ms. Brownley. Thank you very much.
    And in terms of Mr. Stier's opening comments too, with 
regards to demographics within the VA population, I mean, what 
are the challenges that you are facing in attracting 
particularly younger employees?
    Dr. Clancy. Well, understand that except for truly 
exceptional people attracting doctors is going to be getting to 
the upper ends by the time you finish training of the category 
that Mr. Stier was referring to.
    My understanding is that over recent years there has been a 
little bit of a downturn in interest among younger people in 
working for Government writ large. Whether that affects VA more 
than other departments I don't have good information about.
    I will say our Assistant Secretary for HR&A is constantly 
talking about the Pathways initiative and some parts of the 
department use that quite a bit. We can certainly take it back 
to see if the Veterans Health System might be using it more 
vigorously.
    Ms. Brownley. I mean, are we tracking that information--
    Dr. Clancy. Oh, yes.
    Ms. Brownley [continued]. --so we understand where the 
problems and challenges are?
    Dr. Clancy. Yes.
    Ms. Brownley. In terms of this proposed legislation, do you 
have a timeframe when we might hear written views on the 
sections that aren't included in the testimony today?
    Dr. Clancy. I can assure you that literally people are 
working on this right now and we will get it to you as quickly 
as we can.
    Ms. Brownley. Okay. And last and finally on the area on 
Section 9, that again I understand that you weren't able to 
provide your views on Section 9 today, which would expand the 
eligibility for Veterans' Preference in the Federal hiring 
process to both National Guards and Reservists who serve 180 
cumulative days on active duty as opposed to 180 consecutive 
days, and I think as a Federal agency, VA would clearly benefit 
from hiring more Guards and Reservists. Is there a concern that 
expanding eligibility would dilute the Veterans' Preference to 
the point of requiring veterans to compete against each other 
for Federal jobs?
    Dr. Clancy. I am going to ask my colleague Mr. Butler if he 
has more information on that.
    Ms. Brownley. No, it looks like I have run out of time, 
so--
    Dr. Clancy. We will follow-up.
    Ms. Brownley. Okay.
    Dr. Clancy. Can we take that for the record?
    Ms. Brownley. Thank you.
    I yield back.
    Mr. Benishek. Mr. Takano, you are recognized.
    Mr. Takano. Yeah, that is a question on which I am 
interested in hearing the VA's answer. So I will take that 
question up, Ms. Brownley.
    Go ahead.
    Dr. Clancy. All right. Elias, do you want to take that?
    Mr. Hernandez. My humble opinion in that particular section 
is that, you know, our organization strive for hiring veterans. 
You know, we have hiring initiatives in our organization to 
hire more veterans. It is something that we probably have to 
kind of look at it a little bit more closely in terms of the 
impact. Like I say, my personal opinion is that, you know, the 
more veterans that are eligible for our jobs, the greater the 
opportunities for our organization to be able to hire them.
    Mr. Takano. Well, I will just give you this input. I 
represent an Air Reserve base where we have both Reservists and 
Guardsmen, and it is always difficult for them to find a 
flexible-enough employer who will enable them to do their 
reservist duties.
    And so I appreciate that you are going to review the impact 
it would have on the VA and whether or not it would be good or 
bad, but I understand the VFW has some concerns about this. 
And, Mr. Fuentes, would you care to comment on what your 
concerns are about this provision?
    Mr. Fuentes. And just to clarify our position, we support 
the change from cumulative--the change for Guard and Reserve--
we support that section.
    Mr. Takano. Oh, good.
    Mr. Fuentes. What we have concerns with is the change that 
would require VA to comply with certain Title V competitive 
service legislation or law.
    Mr. Takano. Okay.
    Mr. Fuentes. And that was done because the intent of the 
legislation, my understanding is, so that Veterans' Preference 
is opened up to retired veterans, retirees--most are retirees. 
So these are the folks, the officers who served 20 years, who 
would make great executives, who aren't extended Veterans' 
Preference at the moment.
    But it is not that we believe that they shouldn't have 
Veterans' Preference, it is that we feel that by trying to do 
something good, I think you are actually impeding VA's ability 
to hire more expeditiously because you are now requiring them 
to comply with Title V restrictions.
    I don't know if that makes sense.
    Mr. Takano. I do not quite understand. We will explore this 
a little further, but I am glad to hear that you have clarified 
the 180-day consecutive service. So you are not opposing that, 
you are saying that you don't have an objection to that?
    Mr. Fuentes. Not at all. Our written testimony goes into 
how we believe that with our all-volunteer military and the way 
we have been fighting in the last two wars in Iraq and 
Afghanistan, it makes sense that we make this change, that we 
support this change.
    Mr. Takano. Our Reservists and members of the Guard I think 
would feel that this would treat them with respect that we also 
give them a hiring preference.
    Mr. Fuentes. Congressman, if I may, I am a Reservist, 
former Reservist and Afghanistan veteran, so I completely 
understand how this would impact my fellow veterans.
    Mr. Takano. It would have a great impact, I think, on our 
ability to help our Guardsmen find employment that works.
    On the retiree issue, please help me understand this a 
little better. Because I thought that maybe your objection 
might be that we have people who haven't reached the 20-year 
retiree level. I mean, I am thinking that military retirees may 
be in a better place than our veterans with shorter service, 
that being younger, it puts them at a disadvantage.
    Mr. Fuentes. We completely agree, I think that military 
retirees and officers who have served 20 years or more make 
excellent candidates for executives at VA. I think it is the 
vehicle that is utilized to make that happen that we have 
concerns about.
    Mr. Takano. All right. Let's try to talk a little bit more 
about that offline to understand. It seems a little more 
subtle. So I didn't hear the Title V complications. But I am 
glad to hear about your support of the 180-day non-consecutive.
    But just to be clear, the 180-days cumulative versus 
consecutive you are in favor of or you support?
    Mr. Fuentes. Yes, we support that aspect of the section. 
The section has a number of provisions and that one is one that 
we support.
    Mr. Takano. Okay. Well, great. Thank you for your 
testimony.
    Mr. Benishek. Dr. Roe, you are recognized.
    Mr. Roe. Thank you, Dr. Benishek. And thank you, all 
panelists, for being here today. It has been a good discussion, 
I think, and one that needs to be had.
    First of all, I want to just say for the record that, to 
me, a veteran is a veteran. If I didn't know if you served in 
the Reserves, could care less, or the Guard. I was active duty; 
to me, it doesn't matter, you served. But I tell everybody, the 
military ain't Club Med. They send you where they send you and 
where they need you. So whether it is 180 consecutive days, 14 
days in the summer and you never get deployed, you put yourself 
out there to be deployed if you need to be and, to me, that is 
service.
    So I wanted to get that on the record and want you to know 
that I am going to support that type of legislation or whatever 
going forward. I feel like you are a brother just like I am.
    Now, a couple things, I guess, Dr. Clancy, that we were 
looking at. I am concerned about the VA's request to remove the 
VISN or Medical Center directors to be doctors or I would say 
other medical providers on the ground. It is already difficult 
to recruit for these positions and this additional restriction 
will make it nearly impossible in some areas.
    And then, what data do you have to back up the assertion 
that you think that medical expertise is unnecessary when 
recruiting a professional to lead a hospital or a group of 
hospitals?
    Let me give you an example. I don't have an MBA from 
Harvard in business, but I have an MBA from paying bills for 30 
years and running a practice, and managing people and helping 
manage a very large organization. So when you look at that, you 
are just like in the Reservists and Guard, they had that 
military experience, but they also have a civilian experience. 
It is very valuable when they go in the military. They may be 
accountants, they may be mechanics, they may be managers of a 
Walmart, whatever. They bring those skills with them and those 
are valuable leadership skills.
    And it is just like I don't have a Master's in public 
health somewhere, but I have decades of real world experience 
that would be valuable in running a hospital, because I can 
promise you, I know exactly how an OR works, I know exactly how 
a medical floor works, I know exactly how the laundry works and 
especially when it doesn't work, and especially when you don't 
get your instruments sterilized and so on, that a person that 
has never walked in those shoes wouldn't know.
    So how many of our directors at the VISN or otherwise are 
Medical Center directors are medically trained people? Nurse, 
nurse practitioner, doctor, pharmacist, whatever.
    Dr. Clancy. I would have to take that for the record. And I 
take your comment very, very seriously. Some of our best 
Medical Center and network directors have been physicians, some 
of them are now.
    Mr. Roe. Yeah, and it doesn't mean you wouldn't be.
    Dr. Clancy. My only point was, just as you have an MBA in 
paying bills, I am going to guess that you had colleagues who 
probably failed that course or who struggled much more to run 
the business that running a practice requires.
    My only point was that there is expertise in other areas 
that is quite important.
    Mr. Roe. No question. I totally agree with you there. It is 
not because you do practice doesn't mean you ran one and I 
think that is exactly right. But I think you should look.
    I do think that those providers have a different set of 
lenses that they look through and the reason they do, I think, 
is they will always look through it, as you will, Dr. Clancy, 
through the eyes of how everything I do affects a patient and 
the care they get every day. Does it make it better and easier 
for the people that's providing the care, if you have been down 
there actually doing it yourself and you do understand it. So I 
would leave it with that.
    I wonder if the staffing and the other question I have is, 
do you know what the demographics are of the 340-something-
thousand slots that you have or the employees you have at the 
VA, what their ages are? Because if you are like a lot of them, 
I know Eastman Chemicals, a large company in my district, I 
think in the next five years 25 percent of their labor force 
can retire and they don't know what they are going to do. I 
mean, they are trying to train--people are now working longer, 
thank goodness they are. And one of the reasons I think that 
there is not a very, as you pointed out just a minute ago, the 
very young, Mr. Stier, is that it does take us a while to get 
them trained up. You know, I tried as fast as I could to learn 
it, but it is just a lot to learn and it takes you a lot of 
years to do it, and I think that is one of the thing.
    And the other thing I think is, I wonder if this is 
generational. You see people, younger people tend to turn what 
they are doing over a lot more frequently than people in my 
generation who got a job at the plant, worked there for 40 
years and retired. I wonder if it is that also. It is a 
challenge for everybody, not just the VA, is my point.
    Dr. Clancy. I will simply say, we would be happy to give 
you specific numbers on what the age breakdown is. The issue of 
how many people are retirement-eligible is something that we 
watch a lot. As you say, many people for a variety of reasons 
have deferred that decision or in contrast to previous years, 
but it is something we keep a close eye on, and I am going to 
guess Mr. Stier and his colleagues do as well.
    Mr. Roe. Yeah, we know that 10,000 people turned 65 today.
    Dr. Clancy. Yes.
    Mr. Roe. I mean, that is just a fact.
    Mr. Stier. I mean, there is no question that the retirement 
issue is a very prominent one, and I think it is really 
important to look at the mission-critical pieces at VA and not 
just the whole thing. But in general, VA struggles not just 
with the medical directors, but in bringing in young people. It 
is not the medical directors or the doctors themselves, VA is 
not hiring young people in any real number.
    Some of that has to do, again, just on the Pathways side, 
that VA is not doing what any other professional organization 
does, and this is true across government, of taking people in 
as student interns, seeing if they actually work out, and then 
converting them to full-time employees if they do well. That is 
not a model that is used in government more generally or at VA 
in particular, and it is a big mistake, because you can look at 
time to hire, which is the question we were discussing, but you 
really want to look at quality of hire, you want to look at the 
assessment, and there is no substitute for having an 
opportunity to work with somebody.
    So, again, government and VA in particular are not doing 
the most basic thing of seeing student interns as the primary 
hiring entry point, and that is something that could be done. 
You are going to improve the situation with a bill, but 
fundamentally that is going to be a management exercise on the 
part of the VA.
    Mr. Roe. I am sorry, I didn't mean to go over. But I agree 
with you a hundred percent that four of the seven members of my 
staff here in Washington, D.C. came in basically as interns, 
entry-level jobs, and they are great.
    Mr. Stier. And you hired the ones that made sense.
    Mr. Benishek. Thanks, Dr. Roe.
    Mr. O'Rourke, you are recognized.
    Mr. O'Rourke. Thank you, Mr. Chairman. I want to thank you 
and Chairman Wenstrup for your work and the work of other 
Committee Members on this draft legislation, and the work of 
your staffs and the minority staff as well. This is, I think, 
one of the most critical issues for us to be working on, and I 
appreciate the feedback from the VSOs and Mr. Stier and the VA 
on this. Whatever imperfections or improvements that can be 
made, let's get to them as quickly as possible. And I hope that 
the VA, and it sounds like from some of your comments, Dr. 
Clancy, you are, I hope the VA will run with the spirit of this 
and whatever you can do administratively now, do it. You don't 
need to wait for legislation from Congress to do so.
    Last summer we learned that there were 41,500 medical 
positions authorized, appropriated for, but unfilled at the VA. 
What is that number today?
    Mr. Hernandez. Congressman O'Rourke, we do have a number of 
requirements, they have been initiated in WebHR. We don't have 
a precise number of vacancies, due to the fact that we don't 
have a position management system in the organization, but the 
number is currently 43,000 positions, and out of those, 37,176 
are actually on the active recruitment phase.
    Mr. O'Rourke. Okay. So I will just take from your answer, 
if we were at 41,500, we are now at 43. Okay.
    So we are having a really hard time not even treading 
water, but just not sinking all together.
    How many of those 43,000 are behavioral or mental health 
positions?
    Mr. Hernandez. I have the numbers here, let me just find it 
real quickly. There are 3,497 physicians, close to 9,000 
nurses. I have some specific numbers related to mental health, 
you know, there are psychiatric, there are about 3200 of those 
positions--well, let me rephrase that back. There are 3216 on 
board psychiatric, there are 275 actions in the WebHR system 
being recruited.
    Mr. O'Rourke. How many psychiatrists are you short?
    Mr. Hernandez. I don't have that specific data in front of 
me, Congressman O'Rourke.
    Mr. O'Rourke. So this is a request I have made of the 
Secretary already, and I will make it again through you, Dr. 
Clancy. I know the Secretary has a 12-point program to turn 
around the VA, I will again submit it should be a 13-point 
program and point number one should be reduce veteran suicide. 
If we do that, we are going to make decisions, including hiring 
decisions and decisions on where we prioritize accordingly. And 
we will know how many psychiatrists and psychologists and 
social workers short we are, and I think we will make some 
decisions about how we prioritize their hiring.
    I shared with you, Dr. Clancy, that we are at 89 FTEs, 
full-time equivalents, in El Paso for mental health today with 
116 authorized and appropriated for, and we are at a two or 
three-year low for mental health providers. And we know that 
care delayed becomes care denied and results in some tragic 
outcomes, including veteran suicide. So I want to use this 
forum again to ask that we prioritize that.
    Within this bill, I am encouraged to see provisions for 
market pay. My only concern related to that is that perhaps in 
El Paso, which is not a rural area, but an under-served area, 
and then you have rural under-served areas, we may need to go 
far above market pay to get the number of psychiatrists, 
psychologists, behavioral health providers that we need. And so 
that would be a change that I would ask for. Pay whatever it 
costs to get the appropriate person. Understanding that 
American medicine generally is having a hard time producing 
psychiatrists and psychologists and mental health specialists, 
but, you know, there are people in Manhattan who are able to go 
see a psychiatrist about, you know, their dog urinating on the 
carpet, there should be veterans suffering from PTSD who are 
able to see somebody immediately without any question. We just 
need to do whatever it takes.
    And, Mr. Stier, I just have to tell you I really appreciate 
your comments about this being perhaps the starter pistol, and 
what is really needed ultimately is accountability and 
oversight. And for the record, I would love for you to tell us 
what you specifically recommend for that to ensure that we are 
following up on this. Because it can't just be, look, this 
stuff is hard, we can't hire these people, it is hard in 
American medicine, there have to be consequences if there are 
new authorities and resources given to get the job done and to 
prevent veteran suicide and provide greater access for mental 
health.
    So sorry to make a speech and not ask as many questions, 
but I would like the direct answers to those questions I asked 
of you, Mr. Hernandez and Dr. Clancy.
    Dr. Clancy. We will get you that information expeditiously.
    I am going to presume, just to clarify, that getting the 
full spectrum of professionals who provide mental health care 
is what you would like, the social workers, psychologists, 
psychiatrists.
    Mr. O'Rourke. Nurse practitioners.
    Dr. Clancy. Yes.
    Mr. O'Rourke. Everyone involved in the provision of that 
care, so that we can connect veterans who need it, who aren't 
receiving it today, that is what I am looking for.
    Dr. Clancy. We will get that to you expeditiously.
    I will also just insert for one moment that we are 
exercising all of the incentives that, thanks to the Congress, 
were provided in the Clay-Hunt bill as well, because we agree 
with you, whatever it takes; this is an imperative.
    And one other thing. One of the Secretary's 12 
breakthroughs actually does include a component on suicide. It 
is not explicit about the hiring piece, but to do it right, we 
have got to have the hiring piece as well. So that message has 
been heard.
    Mr. O'Rourke. Thank you.
    Mr. Benishek. Dr. Abraham.
    Mr. Abraham. Thank you, Mr. Chairman. And thank you for 
this hearing, it is a great hearing.
    I am going to pick up where Mr. O'Rourke left off, I 
thought his line of questioning was great.
    Mr. Hernandez, you said there was a 60-day period from when 
that applicant hits to when it is a job offer. What percentage 
of job offers that the VA extends are actually taken? What 
percentage of those physicians or nurses that come into the VA? 
Is it a 50 percent, is it a 25? So if you offer a hundred 
positions, how many are taken by the applicants?
    Mr. Hernandez. If I understand the question correctly, out 
of the job offers that we made, you want to know what 
percentage of those--
    Mr. Abraham. Accepted the offer, yes.
    Mr. Hernandez [continued]. --accepted the job offer?
    Mr. Abraham. Yes.
    Mr. Hernandez. I don't have that data with me.
    Mr. Abraham. Okay. If you could, I would appreciate that. I 
think that is important.
    Do you know, in 2015, let's go to DOs and MDs, just 
physicians themselves, how many hires were made by the VA, do 
you have that answer?
    Mr. Hernandez. How many overall hires we did?
    Mr. Abraham. Yes, sir. If you put MDs and DOs together, how 
many hires? Do you have that particular answer?
    And the reason I ask the question, I mean, you said with 
Mr. O'Rourke's question that we had 43,000 open slots, I just 
wanted to see how many are being filled. And you can get back 
to me, that is fine.
    Mr. Hernandez. Yes, I will get back with you.
    Mr. Abraham. I didn't mean to put you on the spot, that is 
not my intent here. My intent is just to get something I can 
wrap my head around and get an answer.
    Mr. Hernandez. Yes, sir.
    Mr. Abraham. Dr. Clancy, I know with the credentialing 
board that the VA has, is there any difference in standards 
between the MDs, the DOs, the DPMs, all the MPs and PAs, is it 
pretty much standard operating procedure across the board as to 
how they are graded before they are offered that job offer?
    Dr. Clancy. Yes. What takes time here is, like many 
institutions, we do primary source verification.
    Mr. Abraham. Right.
    Dr. Clancy. So we are not sort of taking someone's word for 
it, but yes.
    Mr. Abraham. Okay. Mr. Stier, the figures that you have, do 
they agree with Dr. Hernandez as far as that 60-day? I am like 
Dr. Benishek, you know, I am out in the district and I am 
talking to my docs that are trying to get into the VA system 
and they say, you know, it has been over a year. So I just want 
to make sure we are all on the same page here.
    Do your figures go with what the VA is telling us here?
    Mr. Stier. So two things. The first is that I don't have 
access to their direct hire information, so I have no 
independent sourcing. But I would say that what we have heard 
so far is a general number as opposed to the mission-critical 
positions that you are focused on, as I understand it, the 
doctors.
    So I think one of the interesting requests would be, can we 
get information about time to hire for, you know, MDs or DOs, 
so that you have the specific population you are interested in.
    And then I just would like to add again that time to hire 
is relevant, but at the end of the day, you can hire fast or 
slow, if you don't hire well, you have not done the job.
    Mr. Abraham. I totally agree with that.
    Mr. Stier. And I think one of the things that this bill is 
important about is that it is going to also require some 
critical information around applicant satisfaction, hiring 
manager satisfaction. So asking both the population that is 
applying for the job, what was the experience like, and then 
the people who actually need the hires, did you get the talent 
that you actually wanted and relative to, you know, what you 
have been doing in the past. So those things are very 
important.
    I think you heard one other thing that was really critical 
here is the technology. You don't have an integrated HR system 
across the whole agency, so it is very hard to do the kind of 
work that you actually need to do in terms of comparing the 
information and holding folks accountable if you don't have 
that. So that would be another place where I think further 
exploration would help, you know, understand how you can 
improve the situation.
    We don't have, and again VA is not alone, we don't have 
integrated HR platforms, it is a big mistake. Any other large 
organization that is well run in the private sector would have 
it. And it is a big problem in the government and it is not the 
agencies, there is lots of room for blame around. So to fix it, 
I think this is a place that Congress could help.
    Mr. Abraham. Okay.
    Mr. Fuentes. Congressman, if I may--
    Mr. Abraham. Yes, sir, Mr. Fuentes.
    Mr. Fuentes [continued]. --just one quick suggestion.
    Mr. Abraham. Yes, sir.
    Mr. Fuentes. In order to identify the bottlenecks, I think 
one of the things that can be done is really take a look at the 
different segments and their hiring process.
    One of my biggest, I would say, complaints of how VA 
measures things is they select the start date or they select 
the time in which they start measuring. And I think what is 
needed is to really take a look at every single segment of the 
hiring process, from the time that someone has left, or that 
vacancy was created, until the time that we get someone to fill 
that vacancy.
    Mr. Abraham. I understand, good point.
    I yield back, Mr. Chairman. Thank you so much.
    Mr. Benishek. Ms. Titus, you are recognized.
    Ms. Titus. Thank you very much, Mr. Chairman.
    As we have had meetings over the last several years, you 
have heard me say many times that we need to not only focus on 
making it easier for the VA to discipline and dismiss 
employees, but also to recruit and retain the best employees. 
So I want to thank Dr. Benishek and also Dr. Wenstrup and your 
staff for bringing this legislation forward, and for including 
me and my staff in the process as you have drafted it, we very 
much appreciate that.
    I hope also as we continue working on the bill, that we 
will include in it legislation that Mr. Takano and I have 
worked on to kind of continue something we started when we were 
doing the Choice Act, which was to increase the number of GMEs. 
We had that for five years, I hope we can extend that to ten 
years, because we have often heard that where you go to school 
and do your residency is where you stay and practice. And so 
that might also be something that helps with this problem.
    Mr. Stier, your testimony presents some very compelling 
statistics that are pretty upsetting in terms of the retirement 
and the number of people who are going to be retiring, and the 
number of people who think it is not a great place to work and, 
you know, that seems to be a real challenge. But I think it 
also presents us an opportunity, because with this many 
vacancies, it kind of dovetails with the Secretary's position 
of recreating the VA as my VA and making it more veteran-
centric as opposed to agency-centric.
    And so I hope that we take advantage of the opportunity to 
broaden the kind of people we hire. You mentioned that we don't 
have enough young people coming into the program and yet the 
number of young veterans is increasing in my district, it is 
almost as equal to Vietnam veterans at this point, and I think 
that number will overtake the previous war veterans. Also, more 
women are now coming into the VA, LGBT issues are coming in.
    So I wonder if you are doing anything specifically to 
recruit these kinds of employees or if there is anything we can 
do to help you kind of broaden the base of people who are 
coming to work for the VA who can better serve the special 
needs of our new and younger veterans.
    I don't know, we can start with anybody.
    Dr. Clancy. So I will say we have a center for the 
department, and also an Office of Health Equity within VHA that 
reports directly to me that keeps a very close look on this, 
not just to count numbers, which is one step, but actually to 
identify outreach opportunities and opportunities where we can 
encourage a very broad applicant pool. So I did want you to be 
aware of that.
    Obviously, as our affiliates in medical schools and so 
forth themselves become more diverse, that becomes a terrific 
fertile recruiting ground and one that we take very seriously. 
The Secretary has been in more medical schools than I think he 
ever thought possible, but he never misses an opportunity to go 
out on recruiting opportunity for that.
    Ms. Titus. Well, I am glad to hear that, because women 
veterans often tell me they would prefer to see a woman doctor, 
but that there aren't many available. Some transgender veterans 
say there aren't many who kind of understand their special 
issues or can talk to them or relate to them. So I think the 
more diversity you have in your recruiting, the better.
    I didn't mean to cut you off, I'm sorry.
    Dr. Clancy. No, I was going to say that we are making a 
change in the very near future. All of our facilities, and I 
bet Dr. Benishek would know this, have an our doctors Web site, 
but right now you click off by the alphabet. So if I knew that 
I was looking for Benishek, I would click on B, right? We are 
going to make it much easier for veterans to find information 
about physicians that they would be interested in. For example, 
if I want to see a woman physician, I can actually see a photo 
and things like that, and it will be a lot more contemporary 
than our current sites.
    Ms. Titus. Mr. Stier, do you want to add to that?
    Mr. Stier. The one thing that I hope you will find germane 
is that there are a lot of good things that the VA is doing 
right now in terms of on the execution side, but we are coming 
up obviously to an election year, and one of the big challenges 
in government agencies is good work gets started and then it 
gets interrupted because of the change in the leadership.
    And so I think that is an area that this Committee could 
actually assist on in terms of trying to ensure at least two 
things, one of which is, you know, making sure that when there 
is an interruption of political leadership that the agency 
actually has plans to carry forward the good things that are 
going on, and that this Committee holds the next team 
accountable to carrying on the good work. So if there is some 
number of priorities that you want to see occurring, you get at 
them at the very front end.
    And, you know, we heard some discussion about the 
qualifications for Medical Centers and I would ask whether this 
Committee will push on qualifications for leading the VA as 
well, but obviously it is a huge job, it is a huge 
transformation effort, and the kinds of folks that you get into 
those positions and the speed in which you get them there will 
be very important.
    So I am kind of using your question for a little more and I 
hope that is okay.
    Ms. Titus. That is fine, I appreciate that.
    Just real briefly. When we talk about recruiting in under-
served areas, we tend to focus on the rural areas, but also 
some of our inner cities are also under-served. I know I 
represent the heart of Las Vegas. So let's keep that in mind as 
we move forward, those areas can be under-served as well.
    Thank you, Mr. Chairman.
    Mr. Benishek. Dr. Ruiz, you are recognized.
    Mr. Ruiz. Thank you. I would also like to start by saying 
thanks to the leadership of both the Health and Economic 
Opportunity Subcommittees for holding this hearing, and for 
continuing to include my legislation, H.R. 4150, and Section 3 
of the discussion draft.
    The inclusion of other medical professionals other than 
emergency physicians will only continue to ensure veterans 
receive the efficient, effective and continuous care that they 
deserve. By allowing schedulers and managers more flexibility, 
physicians and other care providers will be able to work 
schedules that are more beneficial to the patient and promote 
continuity of that care.
    However, I disagree with the VA's suggestion that the 
language of this section be amended to say, quote, ``is not 
less than,'' unquote, as opposed to, quote, ``does not 
exceed,'' quote. I am concerned that requiring ``is not less 
than'' would likely lead to confusion and potential abuse 
within the department, and ultimately deter medical 
professionals from seeking employment within the VA.
    The point is to match scheduling and work practices with 
the private sector in the emergency department and other shift-
like work like hospitalists who sometimes work a light-shift 
week for maybe one or two weeks and then resume with a very 
heavy-shift work week for one or two weeks that could be more 
or less than a specified number. So the idea is flexibility, 
not to create a rigid, concrete amount as the change in 
language would signify.
    So I urge my colleagues to keep this in mind as we continue 
to develop this discussion draft into legislation. And I look 
forward to continuing the discussion around Section 3 and the 
discussion draft as a whole.
    Let me ask you a question, Dr. Clancy. Does the VA have a 
physician shortage that mimics the general population physician 
shortage?
    Dr. Clancy. Yes.
    Mr. Ruiz. Okay.
    Dr. Clancy. Particularly primary care and mental health. I 
mean, those are tough for us. We got ahead of the curve briefly 
for mental health for the whole system, but because so few 
students are choosing those career paths, that becomes a rate 
limiter, and with mental health parity for the rest of the 
population.
    Mr. Ruiz. And how do you measure that? You know, in the 
United States we have the medically recommended number of one 
physician for 2,000, and to be medically under-served it is one 
to 3,500. What is the recommendation for physicians within the 
VA and how do you measure it? Is it per population? Is it per 
attachment area population of veterans? How many physicians per 
veteran population is your goal?
    Dr. Clancy. I don't think that we have a physicians-per-
veteran-population for the goal, which would be a bit tricky 
because--
    Mr. Ruiz. Do you think we should have one?
    Dr. Clancy. We would be happy to explore that with you 
further. The issues are--that not all veterans in a particular 
area are enrolled in our system and some who are enrolled use 
our system for some services, but not all.
    Mr. Ruiz. So how do you determine need and how do you 
determine physician-shortage need within specific visits within 
specific VA health care systems?
    Dr. Clancy. We determine that by how easy it is for 
veterans to get their needs met, that is literally veterans who 
report that they usually always can get the care that they need 
or want in a timely way, literally. And we actually look very 
closely, as Dr. Wenstrup knows, I am sorry he is not here 
because we have been over this with him a lot, in terms of 
physician productivity, and are we providing the right 
infrastructure support so that they can be as productive as 
possible.
    So it is a very dynamic--
    Mr. Ruiz. So where do you recruit these physicians where 
you have these unfilled vacancies and this physician-shortage 
needs, where is your best place to recruit them? And is the 
military a fruitful place for you to recruit not only 
physicians or residents or maybe perhaps even pre-meds from the 
medic community into the medical school, and then into your 
residency programs and ultimately into your VA?
    Dr. Clancy. I don't know if we have statistics on that, I 
will ask Mr. Hernandez in a second. I want to assure you that 
there is absolutely no source that we don't turn to, whether 
that is the military. Our affiliates and the students who 
rotate through our facilities are a very good source.
    Mr. Ruiz. My specialty, as you know, is emergency medicine 
and I do have public health background and public policy 
background with my educational training, but my on-the-ground 
effort has been to address a physician shortage crisis and how 
to create pipeline programs from very difficult, under-served, 
hard-to-reach communities where you lack physicians, take 
students from those communities into medical schools, into 
residencies, back into those communities.
    So I want to be able to better define the problems that you 
are having using some real analytical tools rather than 
qualitative tools or maybe inaccurate tools of wait times, so 
that we can better match the need with the source, or maybe 
even create a pipeline program from pre-med medics into medical 
schools that feed the VA residency programs and into ultimately 
staying in the VA health care system.
    Dr. Clancy. We would be delighted to work with you on that.
    Mr. Ruiz. Let's work on that.
    Dr. Clancy. Great.
    Mr. Ruiz. Thank you.
    Mr. Benishek. Thank you, Dr. Ruiz.
    Well, that is pretty much it for the questions, but I just 
want to make one more comment that I have been thinking about 
through the whole hearing here. And it is something that since 
I worked within the VA, and I speak to a lot of VA physicians, 
and it is not something that we really addressed here in this 
legislation or the hearing, but my feeling is that with 
speaking to many physicians, that they do not have enough input 
in the way the processes that the VA does where they feel as if 
they are doing things as well as they could.
    And some of the comments Dr. Wenstrup touched on a little 
bit, but my experience is that physicians feel as if they are 
not being as efficient as possible because they don't have 
enough input in the way things are done. The nursing department 
decides how the clinics are run and the physicians may not have 
enough input there.
    And in order to make it a competitive place to recruit 
physicians, they need to have the input to feel as if they are 
doing a good job, because I know things are changing in 
medicine where more and more physicians end up working for a 
big organization because you can't do it.
    But you have to compete with the private sector and I think 
that you really need to work on that issue, because many of the 
physicians are very frustrated with it in the VA. And that the 
whole culture there needs to have physician leadership and 
communication with the medical director and the physicians on 
staff, and a visit to VA is an important part of that. So I 
want to encourage you to make that happen a little easier.
    So thank you all for being here again today. Does anyone 
have any other questions?
    The panel is now excused.
    I ask unanimous consent that all Members have five 
legislative days to revise and extend their remarks and include 
extraneous material.
    Without objection, so ordered.
    This hearing is now adjourned.

    [Whereupon, at 3:25 p.m., Subcommittees were adjourned.]




                            A P P E N D I X

                              ----------                              

                    Prepared Statement of Max Stier
    Chairman Benishek, Chairman Wenstrup, Ranking Member Brownley, 
Ranking Member Takano, members of the Subcommittee on Health and 
Subcommittee on Economic Opportunity, thank you very much for the 
opportunity to share the Partnership's views of the Subcommittees' 
draft legislation to improve the authority of the Secretary of Veterans 
Affairs to hire and retain physicians and other employees.
    I am Max Stier, President and CEO of the Partnership for Public 
Service, a nonpartisan nonprofit organization that works to revitalize 
our federal government by inspiring a new generation to serve and 
transforming the way government works.

Background

    On May 15, 2015, the Partnership submitted a statement to the 
Subcommittee on Health addressing how the Department could overcome 
barriers to efficient and effective staffing of medical and non-medical 
personnel \1\. In our statement, we discussed how VA employees are 
deeply committed to the Department's mission, but the agency as a whole 
struggles with declining morale and an inefficient hiring process. We 
recommended three ways VA could improve its talent acquisition 
processes: reforming the hiring process, standardizing onboarding 
across the organization, and placing renewed focus on employee 
engagement efforts. The Partnership reinforced those recommendations at 
the Subcommittees' December 2, 2015 Roundtable on Veterans Affairs 
Hiring. I am pleased to note that the legislation being discussed today 
would address each of these recommendations in a substantive and 
meaningful way, and would, I believe, improve the Department's ability 
to recruit, hire and retain the top-quality talent our Nation's 
veterans deserve.
---------------------------------------------------------------------------
    \1\ Statement of Max Stier, President and CEO of the Partnership 
for Public Service - Prepared for The House Committee on Veterans' 
Affairs Subcommittee on Health Hearing Entitled, ``Overcoming Barriers 
to More Efficient and Effective VA Staffing'', 114th Cong. (2015) 
(testimony of Max Stier). Print.

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VA Must Do More to Bring in Young Talent

    The ability of the Department of Veterans Affairs to care for and 
support America's veterans depends on how well it can recruit, hire and 
retain highly qualified and engaged employees, particularly in the 
medical field. Unfortunately, the Department has struggled to bring in 
and hold on to top talent, with some reports showing nearly 41,000 
vacancies at the Veterans Health Administration alone. \2\ VA employees 
recognize these challenges as well. According to a Partnership for 
Public Service analysis of the Office of Personnel Management's (OPM) 
2015 Federal Employee Viewpoint Survey, fewer than half of VA's 
employees responded positively to the statement, ``My work unit is able 
to recruit people with the right skills'' (43.2%), while a bare 
majority of VA employees (51%) believe ``the skill level of my work 
unit has improved over the past year.''
---------------------------------------------------------------------------
    \2\ Hoyer, Megan. ``Half of Critical Positions Open at Some VA 
Hospitals.'' USA Today. 4 Sept. 2015. Web. 1 Mar. 2016.
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    Recruitment and retention issues are exacerbated by an aging 
workforce which is becoming eligible for retirement in increasing 
numbers. For example, GAO found that by FY 2019 one in five VA nurses 
will be able to retire 1A\3\, while 42% of VHA's overall senior 
leadership, including medical professionals, was retirement eligible in 
2015. 1A\4\ In order to create a balanced workforce and meet both 
short- and long-term talent needs, VA must do more to recruit and hire 
students and recent graduates, and millennials more generally. Focusing 
efforts to bring in young talent now has the additional benefit of 
allowing new employees to learn from thousands of talented, dedicated 
and experienced medical professionals, benefits administrators, and 
mission-support staff before they leave the organization.
---------------------------------------------------------------------------
    \3\ 1AUnited States of America. Government Accountability Office. 
VA Health Care: Oversight Improvements Needed for Nurse Recruitment and 
Retention Initiatives. Washington, D.C., 2015. Page 9. Print.
    \4\ 1AIbid. 21.
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    The Department's own 2014 Interim Workforce and Succession 
Strategic Plan noted that by the end of the decade the U.S. workforce 
will be approximately 50% millennials. 1A\5\ The Department of Veterans 
Affairs cannot be left behind. However, to date VA has struggled to 
build pipelines of young talent. In 2015, just 0.68% of VA's workforce 
was under the age of 25 and 5.35% were under the age of 30. In terms of 
hiring, 15.7% of new VA hires were under the age of 30, while the 
comparable government-wide figure was 25.2%, according to OPM's 
Fedscope database. In 2014 millennials made up 11.3% of the Veterans 
Health Administration workforce, where the bulk of the Department's 
employees reside. 1A\6\ Exacerbating this problem is low satisfaction 
among younger employees. The latest Best Places to Work in the Federal 
Government Rankings, published by the Partnership for Public Service 
and Deloitte, found that VA ranked second-to-last among large agencies 
in satisfaction among employees under the age of 40.
---------------------------------------------------------------------------
    \5\ 1AUnited States of America. Veterans Health Administration. 
Healthcare Talent Management, Workforce Management & Consulting Office. 
2014 VHA Interim Workforce and Succession Strategic Plan. Page 13. Web.
    \6\ 1AIbid. 24.

Partnership Views of the Draft Legislation to Improve VA's Authority to 
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    Hire and Retain Physicians and Other Employees

    Because several sections of the proposed legislation are outside of 
the Partnership's areas of expertise, I will focus my remarks on those 
provisions on which we are best equipped to comment. My remarks below 
address each relevant section individually.

Section 2. Appointment and Pay for Directors of Medical Centers and 
    Veterans Integrated Services Networks

    The Partnership supports greater use of market pay as a mechanism 
for attracting and rewarding top talent in government, though we do not 
have a specific view as to the qualifications standards for medical 
center and Veterans Integrated Service Network directors. The 
Partnership's 2014 report with Booz Allen Hamilton, Building the 
Enterprise: A New Civil Service Framework, states that the current 
federal pay system undermines government's ability to attract and 
retain high-quality professional and administrative personnel and 
proposes a market pay system that recognizes distinctions between job 
types, compensation, and performance common in the private sector. We 
are pleased to see the Subcommittees expanding this concept to these 
critical, high-visibility positions.

Section 7. Executive Management Fellowship Program

    The Partnership has long supported efforts to expand the mobility 
of government employees and senior executives across agencies and 
between government and the private sector. For that reason, we strongly 
support the draft legislation's Executive Management Fellowship 
Program, which would provide a one-year fellowship to eligible 
employees to work in private sector organizations engaged in the 
administration and delivery of health care or other benefits. In 2012 
the Partnership and McKinsey and Company issued a report titled, 
Mission-Driven Mobility: Strengthening Our Government through a Mobile 
Leadership Corps, examining how the SES could meet its promise of 
serving as a mobile, enterprise-wide leadership team as originally 
envisioned by the Civil Service Reform Act of 1978. Our report 
describes the powerful positive impacts of mobility in building 
executive managerial skills, strategically filling vacancies, and 
infusing new thinking into an organization. Senior career employees at 
VA will benefit from access to diverse perspectives, a breadth of 
experience, and a deeper understanding of the private sector's 
processes, technologies, and operational framework. The Executive 
Management Fellowship Program, aimed at SES and aspiring senior 
executives, if well-executed, offers to bring significant benefits to 
VA's senior executive corps.
    We recommend the Subcommittees consider two changes to the 
Executive Management Fellowship Program as currently constructed. 
First, we suggest increasing the program's cap of 30 participants, for 
example by initially implementing the Fellowship as a pilot program 
with a participant cap to determine its effectiveness, and then opening 
it up to a larger number of participants if warranted. To ensure that 
only the best employees are able to participate, the Subcommittees 
should also consider requiring eligible employees to have at least two 
consecutive outstanding ratings. The combined workforce of VHA and VBA 
is nearly 293,000, and there are more than 7,000 eligible participants. 
Cost concerns aside, the vast size of this workforce means that a cap 
of 30 participants will severely limit the program's potential impact. 
The Partnership believes mobility is a worthwhile investment, and would 
demonstrate to senior VA employees that their agency values them and is 
willing to invest in their development. Our second recommendation is to 
look at ways in which the Fellowship program could be made into a two-
way exchange, in which individuals from the private sector come to VA 
to share cutting-edge operational techniques and best practices.

Section 8. Accountability of Leaders for Managing the Department of 
    Veterans Affairs

    The Partnership strongly supports the draft legislation's provision 
requiring political appointees at the Department to undergo a 
performance planning and appraisal process similar to that of the 
Department's career senior executives. We additionally recommend that 
the Subcommittees look into how VA could create connectivity between 
the performance expectations for political appointees and career 
executives. Though political appointees and career executives face 
different demands and operate at different levels of the organization, 
aligning performance expectations in this way can help needed reforms 
and accountability cascade throughout the organization.
    As the highest level of leadership in the Department of Veterans 
Affairs, political appointees play a crucial role in providing 
leadership and setting priorities for the organization. Appointees 
should be held accountable for their performance and contributions like 
every other employee. Data from the Partnership's analysis of the 
latest OPM Federal Employee Viewpoint Survey demonstrates why this 
provision is so important: in 2015, just 32.7% of VA employees 
responded positively to the statement, ``In my organization, senior 
leaders generate high levels of motivation and commitment in the 
workforce'', and only slightly more, 38.5%, positively responded to the 
statement ``My organization's senior leaders maintain high standards of 
honesty and integrity.'' Appraising and holding accountable political 
leaders for setting priorities and expectations, and developing an 
empowering and engaged culture throughout the organization, will help 
to restore trust in senior leadership.
    We are particularly pleased that the performance plans will address 
the accountability of leaders for promoting good practices and 
supporting efforts to recruit, select and retain well-qualified 
individuals, engage and motivate employees, train and develop future 
leaders in the Department, and hold managers accountable for addressing 
performance issues. Each plays a critical role in building a high-
performing workforce, and will further drive leadership attention to 
the pressing workforce issues within the Department. However, engaging 
and motivating employees may be one of the most immediate and impactful 
ways by which senior political appointees at VA can make an impact. As 
noted above, fewer than four in ten VA employees feel that their senior 
leaders are motivating them. The Partnership's Best Places to Work in 
the Federal Government Rankings put VA employee satisfaction with 
senior leaders at 18 out of 19 large agencies. GAO has also found that 
employee dissatisfaction negatively impacts the ability of VHA to 
retain employees in mission-critical occupations. 1A\7\
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    \7\ 1AUnited States of America. Government Accountability Office. 
VA Health Care: Oversight Improvements Needed for Nurse Recruitment and 
Retention Initiatives. Washington, D.C., 2015. Page 17. Print.

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Section 9. Modification of Veterans Preference

    While the Partnership supports the goal of a diverse federal 
workforce, including the continued recruitment and hiring of veterans, 
we have concerns over the proposed legislation's expansion of veterans' 
preference to the Senior Executive Service. The Senior Executive 
Service is, by law, excluded from the application of veterans' 
preference, and applying such preference specifically to VA would put 
the Department at a disadvantage when competing for executive talent 
with other agencies and the private sector. Requiring, as the proposed 
legislation does, that VA should select candidates for senior executive 
positions ``in the same manner and under the same conditions required 
for the competitive service'' may further hinder the VA's ability to 
recruit diverse talent with the skills the Department badly needs, such 
as in hospital administration and critical mission-support functions 
such as human resources, information technology, and financial 
management.
    We ask the Subcommittees to consider other ways to increase the 
number of veterans in senior executive positions that do not 
unnecessarily restrict the Department's ability to bring in the 
executive talent needed to complete its transformation process. 
Concerns about a relative paucity of veterans in top leadership 
positions is a valid concern, and there are substantive ways in which 
the Subcommittees and VA can work together to address it. For example, 
while VA does not have specific leadership development programs aimed 
at employees who are veterans, the Department can increase its efforts 
to encourage veteran employees to participate in its two primary 
leadership development programs, LeadershipVA and the Senior Executive 
Service Candidate Development Program, which prepare employees for 
senior leadership positions. VA could also enhance its outreach to the 
broader veterans' community to recruit external veteran candidates for 
SES jobs at the Department. Such an approach would require VA to work 
with these candidates to help them navigate the SES application 
process, though we believe it is well worth the effort.

Section 10. Reemployment of Former Employees

    The Partnership enthusiastically supports granting VA authority to 
noncompetitively appoint qualified former employees of VA to any 
competitive or excepted service position at the agency - an issue the 
Partnership discussed in our report, Building the Enterprise: a New 
Civil Service Framework. As the report notes, current law allows a 
former employee who has held a career or career-conditional position to 
be noncompetitively reinstated only at a grade level at or below that 
which they held before leaving government. This change, provided for in 
the draft legislation being discussed today, will give VA greater 
flexibility in bringing back employees who have gained valuable 
training and work experience in their time away from the Department, 
and would provide an additional incentive to employees who are 
considering a return to VA.
    We suggest, however, that the Subcommittees consider going further. 
Specifically, we would recommend removing the one grade level limit and 
opening the opportunity for noncompetitive reemployment to all federal 
employees, rather than just those previously employed at the 
Department. By removing this limitation, VA would offer further 
enticement to those former employees who are more advanced in their 
careers, providing the Department with an additional method by which it 
could recruit mid-career and senior-level talent. Opening the 
noncompetitive reemployment opportunity to all federal employees would 
give VA a leg up in recruiting talent from other agencies with similar 
workforces (e.g., HHS, NIH, DOD, etc.) and recognize the enterprise-
wide nature of the challenges that agencies like VA face in hiring top 
talent. We understand and appreciate the concern over the potential of 
this flexibility to be used improperly, but believe this could be 
easily addressed by requiring the VA Inspector General or the 
Government Accountability Office to audit the use of this hiring 
authority within a specific timeframe to ensure that it is being used 
as intended. VA could also report on the use of this authority as part 
of the hiring effectiveness measures in Section 15.

Section 11. Recruiting Database

    The Partnership supports the draft bill's requirement for the 
Department of Veterans Affairs to create a Department-wide database for 
vacant mission-critical and hard-to-fill positions, particularly those 
that have been vacant for a prolonged period of time. VA's 
decentralized hiring processes have led to many facilities competing 
for similar talent, and has prevented the Department from addressing 
critical shortages where they exist. The recruiting database will help 
VA move closer to an enterprise-wide hiring system that can effectively 
address recruitment, hiring and retention challenges where and when 
they occur, rather than simply hoping candidates for VA jobs find their 
way to the facilities where they are needed most. We recommend that VA 
consider how it can combine the recruiting database authorized by this 
legislation with the recently-enacted Competitive Service Act, which 
allows agencies to hire off each other's certification list for a 
position. The Partnership believes the Act has the potential to greatly 
facilitate the filling of mission-critical positions both government-
wide and within the VA, and we encourage VA to work with the Office of 
Personnel Management to make the best possible use of this new 
authority.

Section 12. Human Resources Academy

    The Partnership supports all efforts to strengthen the federal 
human resources workforce. Our May 15, 2015 statement for the 
Subcommittee noted that VA HR staff tend to ``post and pray'' when 
hiring for key positions and receive limited training in workforce and 
succession planning. A September 2015 GAO report on the recruitment and 
retention of nurses also found that a lack of sufficient administrative 
support from HR departments at individual VHA facilities limited the 
extent to which those facilities could take advantage of recruitment 
and retention tools, though this report cited a lack of resources for 
HR teams as having just as big an impact as training. 1A\8\ The 
decentralized nature of VA's hiring system also tends to mean that 
recruiting and hiring is not done strategically and special hiring 
authorities and flexibilities are not used to the extent that they 
could be.
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    \8\ 1AIbid. 17.
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    The Department currently operates a ``VA HR Academy'', which 
provides access to training, career pathing tools like [email protected], and 
an HR competency model for VA HR employees to use as part of their 
professional development 1A\9\, but it has been underfunded in recent 
years. This legislation provides an opportunity to bring greater 
prominence and renewed focus to this underutilized resource. 
Specifically, the goals of the legislation to provide more training on 
best practices in recruiting and hiring mission-critical talent should 
be integrated into a strengthened HR Academy. The Subcommittees should 
request more information from VA on the current status of the HR 
Academy, and on ways the Academy's offerings can best be tailored to 
meet the intent of this legislation and the Department's most pressing 
current talent needs. Reviving the VA HR Academy has the potential to 
address the challenges this draft legislation seeks to take on, and 
could even help increase engagement among VA's HR workforce. The 
Partnership's 2015 Best Places to Work in the Federal Government 
Rankings showed the cohort of human resources employees at VA ranked 10 
out of 18 large agencies in overall satisfaction.
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    \9\ 1A``VA HR Academy.'' Home. Department of Veterans Affairs, 17 
Nov. 2014. Web. 09 Mar. 2016.
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    In 2012, the Partnership's Vice President of Policy John Palguta 
testified before the Senate Homeland Security and Governmental Affairs 
Subcommittee on the Oversight of Government Management, the Federal 
Workforce and the District of Columbia on building and maintaining an 
effective federal human resource workforce 1A\10\. His testimony 
emphasized the important role HR plays in acting as a strategic advisor 
and business partner supporting the mission side of the organization 
and advocated for directing more resources to the federal HR workforce. 
Not only can better training for HR staff improve the quality of talent 
coming into VA, but has huge potential to improve morale and 
engagement, increase retention, and reduce turnover costs.
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    \10\ 1AStatement of John Palguta, Vice President of Policy, 
Partnership for Public Service - Prepared for The Senate Homeland 
Security and Governmental Affairs Subcommittee on Oversight of 
Government Management, the Federal Workforce, and the District of 
Columbia titled ``Building and Maintaining and Effective Human Resource 
Workforce in the Federal Government'', 112th Cong. (2012) (testimony of 
John Palguta). Print.
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    Finally, we recommend both to the Subcommittees and to VA that the 
training provided by the VA HR Academy also include best practices for 
HR staff in effectively engaging with hiring managers to maximize the 
success of the hiring process and satisfaction with new hires, and to 
think more holistically about how other aspects of VA's HR processes 
impact its ability to use the tools, flexibilities and authorities 
available. Another recommendation to the Subcommittees would be to 
expand the availability of training beyond just human resources staff 
to all VA employees who are engaged in recruitment activities. We hope 
the Subcommittees will consider other ways by which more attention and 
resources can be directed to VA's human resources offices and staff, 
for example by specifically authorizing money for non-medical, mission-
support training at the Department that will be protected from use for 
other administrative or personnel activities. HR plays a crucial role 
in ensuring that VA has the talent it needs to serve veterans, and we 
appreciate the Subcommittees substantive action in this area.

Section 13. Promotional Opportunities for Technical Experts

    The Partnership is highly supportive of the draft legislation's 
provision requiring the Secretary of Veterans Affairs to establish a 
promotional track system for employees of the Department who are 
technical experts. The rigid structure of the GS system requires 
employees to move into supervisory and management roles, even in cases 
where the employee may not be an effective manager but must take on 
such duties in order to advance in their career. This is especially 
true for employees who possess valuable technical expertise but are not 
suited for supervisory duties. Such employees may include medical 
professionals or experts in veterans' benefits law who possess valuable 
expertise in complex subjects.
    However, we believe this provision can be further strengthened by 
making explicit that the Department should evaluate candidates for 
managerial or supervisory roles based on their executive and people 
skills as well as their technical expertise, and give candidates the 
opportunity to develop these skills. Like most other federal agencies, 
VA does not have a standard criteria for promoting managers. As noted 
above, managers are often promoted based on the technical expertise 
relevant to their particular organization (e.g., VBA will look for 
managers with strong knowledge of claims administration). We recommend 
the Subcommittee consider language requiring aspiring supervisors and 
managers to demonstrate leadership skills either through their day-to-
day work or through an educational requirement. This educational 
requirement could take the form of online or in-person classes 
developed and advertised through VA Learning University (VALU). 
Employees would not be able to advance into supervisory or managerial 
positions without being certified as having taken such a course. This 
would be a high-impact and light lift for the Department. Not only 
would it guarantee that every new manager understands the basic tenets 
of effective leadership, but would allow those individuals who are not 
fit for management to realize it before they take on a supervisory 
role. Only those employees who have the competencies necessary to be 
successful would become supervisors.

Section 14. Comptroller General Report on Succession Planning

    The Partnership supports the requirement included in this draft 
legislation requiring the Comptroller General to report on succession 
planning efforts at the Department of Veterans' Affairs. According to 
Secretary McDonald's statement before the House Committee on Veterans' 
Affairs on February 10, 2016 1A\11\ the Veterans Health Administration 
hired over 41,000 employees in 2015, though that hiring resulted in a 
net employment gain of about 14,000 staff. This, combined with the 
figures on retirements cited earlier, suggests a high level of turnover 
at the Department, and a need for a robust succession management 
process. The Partnership believes this report would be useful in 
helping the Department better understand the quality of succession 
planning going on throughout the organization and in developing a more 
consistent succession planning strategy. While VHA currently conducts 
strategic planning across its network of facilities 1A\12\, the GAO's 
report would give Congress better visibility into the extent and 
usefulness of workforce and succession planning activities at these 
individual facilities, as well as at other facilities across the VA. As 
the Partnership's 2011 report with Booz Allen Hamilton, Preparing the 
People Pipeline: A Federal Succession Planning Primer noted, succession 
planning is an effective tool for dealing not only with departures but 
also with retention by helping managers determine the critical skills 
that exist within their teams and how to develop and keep needed 
talent. The Partnership encourages VA to use this report to further 
refine and strengthen its internal succession planning processes, 
ensure that such processes are consistent across the organization, and 
tie them to the measures of hiring effectiveness required to be 
collected under Section 15.
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    \11\ 1AStatement of the Honorable Robert A. McDonald, Secretary of 
Veterans Affairs, For Presentation Before the House Committee on 
Veterans' Affairs, ``Budget Request for Fiscal Year 2017'', 114th Cong. 
(February 10, 2016). Print.
    \12\ 1AUnited States of America. Veterans Health Administration. 
Healthcare Talent Management, Workforce Management & Consulting Office. 
2014 VHA Interim Workforce and Succession Strategic Plan. Page 5. Web.

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Section 15. Information on Hiring Effectiveness

    The Partnership applauds the Subcommittee's decision to include in 
its proposed legislation a mandate for VA to measure and report on the 
effectiveness of its hiring process, and we believe this requirement 
can be further strengthened. As I noted at the Roundtable on VA hiring 
hosted by the Subcommittees in December, you cannot manage what you 
cannot measure. VA must have actionable data in order to properly 
understand and address persistent hiring challenges. Yet the Department 
appears to lack a comprehensive understanding of the strengths and 
weaknesses of its hiring process. The language proposed here would 
require VA to collect and publically report on the effectiveness of its 
recruitment programs and hiring authorities, the quality of new hires, 
time-to-hire, applicant and employee satisfaction with the hiring 
process, and new hire satisfaction with onboarding, among other things. 
These data should allow VA to construct a fuller picture of its hiring 
process, including specific points where the process bogs down. 
Developing a fuller understanding of the use of special hiring tools, 
authorities and flexibilities is especially critical, as Congress has 
authorized a number of programs and tools at VA to promote hiring, 
particularly of medical professionals, such as the Education Debt 
Reduction Program, the Employee Incentive Scholarship Program, and 
various recruitment, retention and relocation incentives.
    To make this report even more valuable both to VA and to Congress, 
the Subcommittees should look at including a measure of ``customer 
satisfaction'' of hiring managers and new employees with VA's human 
resources offices, for example by asking their views of the information 
and support they received from their HR offices. It is worth noting 
that VA has collected this data in the past. Such a measure, if 
included, should also specify that data should be taken from HR offices 
across the VA enterprise, where the vast majority of hiring and other 
personnel actions take place. We encourage the Subcommittees to look 
into the administration's and VA's work to benchmark costs and best 
practices across agency mission-support functions and how these efforts 
can be further encouraged, a process that involves analyzing customer 
satisfaction in each function. VA is currently tasked with benchmarking 
administrative spending and identifying performance improvements 
opportunities in the areas of real property and financial management 
1A\13\. An expansion of the benchmarking effort to VA's HR by the 
administration would go a long way towards fixing the organization's 
talent issues. We also recommend that, as part of the Department's 
requirement to share this information to Congress, it be asked to 
report on the biggest pain points in or barriers to effective hiring. 
We believe this is an effective way for the Subcommittees to engage 
with VA on any additional reforms necessary to improve its hiring 
process.
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    \13\ 1AUnited States of America. Office of Management and Budget. M 
0914 0912: Memorandum for the Heads of Executive Departments and 
Agencies: Management Agenda Priorities for the FY 2016 Budget. By Brian 
C. Deese. July 18, 2014. Web.
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    It is, however, important to understand that VA's HR systems, as 
currently constructed, are not built to collect and centralize this 
information. In fact, this problem is not unique to VA - nearly every 
agency lacks such a system. While VA is currently developing an 
integrated human resources information system, it is still in its early 
stages and rudimentary. Personnel databases are scattered across the 
organization and within each of the Department's individual 
subcomponents, and each subcomponent owns its own data. The bill as 
written requires VA to fully commit to constructing a centralized 
information system. This is a very worthy goal, and something we 
encourage the Department to pursue. It is important to understand, 
though, that it will take time. However, the Subcommittees' draft 
legislation can serve as a useful focusing mechanism for the Department 
and prompt quicker development of this system.

Section 16. Employment of Students and Recent Graduates

    The Partnership is highly supportive of the draft legislation's 
provision codifying the Department's authority to convert Pathways 
program participants to full-time entry-level positions. At the 
Subcommittees' December roundtable on VA hiring, I emphasized how 
student interns and recent graduates provide the best way for the 
Department to assess and hire top young talent into the organization. 
Increasing the number of young people in an organization can provide 
fresh ideas, reinvigorate the workforce, and provide a pipeline of 
future leaders. This is true even at VHA, which could take advantage of 
students and recent graduates to fill nursing, physician assistant and 
mission-support roles. Increasing the number of students and recent 
graduates in VA's workforce is critical given the overall dearth of 
young talent at VA which I noted earlier. The private sector makes 
significant use of student interns as a talent pipeline for entry level 
positions, but government squanders the opportunity to make use of this 
talent pool. Government as a whole, and the Department of Veterans 
Affairs in particular, needs to normalize the way interns are utilized. 
While the administration's 2010 hiring reform, which included the 
Pathways internship programs, has made some progress, we do not believe 
it has been enough. The Partnership is very pleased that the 
Subcommittees have included this provision, which would codify VA's 
existing authority under the Pathways programs to make excepted service 
appointments of student interns, volunteers with substantive duties, 
and interns contracted through third-party organizations. This change 
would demonstrate Congress' support for Pathways and push VA to expand 
its use of the programs, which VA has already committed to implementing 
in its 2014 Interim Workforce and Succession Strategic Plan. 1A\14\ 
Ultimately, we believe this provision will increase the pool of proven, 
high quality entry-level talent available to VA.
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    \14\ 1AUnited States of America. Veterans Health Administration. 
Health are Talent Management, Workforce Management & Consulting Office. 
2014 VHA Interim Workforce and Succession Strategic Plan. Page 64. Web.

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Section 17. Exit Surveys

    The Partnership supports mandating in statute an exit survey for 
employees who voluntarily separate from the agency, and we are 
particularly pleased that the Subcommittees have included a reporting 
requirement that will ensure that the Department is using the survey 
data to improve retention of VA employees, especially those in mission-
critical occupations. VA Directive 5006 currently requires the 
Department to conduct a voluntary exit survey of employees separating 
from the organization, but we believe the survey is underutilized and 
that this provision will strengthen the survey and bring it renewed 
focus. Holding on to mission-critical talent requires understanding the 
reasons employees are leaving in the first place, and so VA's ability 
to continue to strengthen its hiring process requires that the 
Department can measure its success and hold itself accountable for its 
improvement. We would encourage the Department of Veterans Affairs to 
use this mandate from Congress to make its current exit surveys more 
robust, participation more widespread and data more widely available to 
key stakeholders inside and outside of the organization. To this end, 
the Subcommittees should consider requiring the Department to 
publically report aggregate exit survey data. VA must make special 
efforts to ensure that these data, in combination with the other hiring 
and workforce planning information required to be collected by this 
legislation, is available to all human resources offices and hiring 
managers, and is actually being used to develop a comprehensive 
strategy for bringing in and holding on to the talent the Department 
needs. Data from the 2014 VHA Interim Workforce and Succession 
Strategic Plan proves the need for this effort - the report showed that 
only 25.8% of VA employees exiting the organization had their manager 
or supervisor talk to them about changing their mind 1A\15\. Keeping 
all of this in mind, we encourage the Subcommittees to continue to 
conduct meaningful oversight of VA's hiring processes and workforce 
management.
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    \15\ 1AIbid. 22

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Enablers of Effective Implementation

    The Partnership believes this legislation has tremendous potential 
to improve the Department's recruitment, hiring and retention of 
dedicated professionals to serve our Nation's veterans. However, if the 
proposals offered here are to be meaningfully implemented, the 
Subcommittees must pay special attention to certain key enablers of 
that implementation. Legislation does not exist in a vacuum; it must be 
executed within an organization with unique strengths, weaknesses and 
challenges. If the Department's leadership is not committed, or not 
supported in making these changes happen, the odds of success become 
much longer. Should this legislation pass, its execution will deserve, 
and require, the Subcommittees' sustained attention. Below I identify 
several key enabling factors that will impact the potential of this 
legislation to bring about significant, positive change to how the 
Department manages its talent:

     Support from Congress for VA employees - Congress has an 
important constitutional duty to ensure that VA serves veterans 
efficiently, effectively and with the respect they have earned. The 
Department's employees are ultimately accountable to Congress, but 
Congress is also accountable to employees as the steward of the VA's 
resources and priorities. We urge the Committee to work constructively 
with VA to address challenges facing its workforce, and to recognize 
the vast majority of VA's employees who are hard-working, patriotic 
public servants who have dedicated their professional lives to serving 
America's veterans. The public image of VA, which Congress has a hand 
in shaping, plays as important a role in supporting recruitment and 
retention as any single initiative of the Department.
     Recognizing the impact of recent proposals on VA's senior 
executive workforce - The Secretary's recent proposal to place the 
Department's senior executive corps under Title 38 grants greater 
flexibility to VA in hiring, paying and, if necessary, disciplining 
executives. However, the proposal will complicate the leadership and 
morale picture at VA. If that proposal moves forward, the Subcommittees 
should conduct rigorous oversight to ensure that it complements the 
intent of this legislation and furthers the goal of bringing top 
executive talent into the organization.
     Clear accountability for implementation - As written, the 
bill does not provide for specific individuals to be responsible for 
implementing the various programs, flexibilities and reporting 
requirements this legislation creates. It is critically important to 
keep in mind that there is no one human resources office at VA. Day-to-
day program and policy implementation is handled by the human resources 
offices of the Department's subcomponents, and truly effective 
implementation will require the Subcommittees to, within the bill 
itself, delegate specific responsibilities or allow the Secretary to 
delegate specific responsibilities to those individuals best situated 
to make these improvements happen.
     Development of a centralized, integrated VA human 
resources information system (HRIS) - VA, like nearly all federal 
agencies, lacks a single repository of personnel data. Instead, data 
critical to understanding the state of VA's workforce and hiring 
processes is scattered throughout the organization. While the 
Department is developing a HRIS, it should not be assumed that VA's 
central HR office can pull this data together easily. The Subcommittees 
should sufficiently resource and conduct meaningful oversight of VA's 
efforts to build an accurate, usable and fully integrated personnel 
information system.
     Sufficient resources for training and development - 
Training is one of the most effective means by which VA can retain the 
best and brightest employees, improve morale, and reduce turnover 
costs. However, funding available for non-medical training at the 
Department has declined in recent years and has hurt its ability to 
provide quality developmental opportunities to employees, particularly 
those in mission-support functions such as human resources, who are at 
the front lines of the VA's efforts to recruit top talent. Further 
complicating this picture is that such funds can be lumped in with 
other personnel costs and used for purposes other than staff 
development. The Subcommittees, as well as the Appropriations 
Subcommittee on Veterans Affairs, Military Construction, and Related 
Agencies, should ensure sufficient, dedicated funding for quality, 
recurring training for the mission-support services that enable the 
Department's work.
     Maintaining momentum through the transition - There are 
roughly ten months left in the current administration, and many of the 
Department's key leaders will soon be gone. The commitment of current 
leadership to executing on this legislation will, potentially, be 
limited by an unwillingness to take on bold and time- and resource-
intensive new initiatives. The Subcommittees provide important 
continuity across administrations, and so we urge you to sustain your 
commitment to building a strong, engaged and effective VA workforce.

Conclusion
    Chairman Benishek, Chairman Wenstrup, Ranking Member Brownley, 
Ranking Member Takano and members of the Subcommittees on Health and 
Economic Opportunity, thank you for the opportunity to give the 
Partnership's views of this legislation. The draft bill we are 
discussing today will make a meaningful and positive impact on the 
ability of the Department of Veterans Affairs to recruit, hire and 
retain the talent it needs to achieve its mission, and we are pleased 
to support it. I look forward to continuing to work with your 
Subcommittees to advance this legislation. Thank you, and I am happy to 
answer any questions you may have.

                                 
                 Prepared Statement of Roscoe G. Butler
    As far back as 1998, The American Legion expressed concerns 
regarding VA physicians and medical specialists staffing shortages 
within the Veterans Health Administration (VHA). This was accomplished 
by monitoring the progress in establishing patient centered primary 
care within each Veterans Integrated Service Network (VISN), including 
both rural and urban localities as well as ensuring that the model of 
care features both the quality and efficient combination of medical 
professionals that are tailored to the needs of the local veteran's 
population. 1A\1\
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    \1\ 1AResolution 311: The American Legion Policy on VA Physicians 
and Medical Specialists Staffing Guidelines
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    Chairmen Benishek, Wenstrup, Ranking Members Brownley, Takano and 
distinguished members of the Subcommittees on Health and Economic 
Opportunity on behalf of National Commander Dale Barnett and The 
American Legion; the country's largest patriotic wartime service 
organization for veterans, comprising over 2 million members and 
serving every man and woman who has worn the uniform for this country; 
we thank you for the opportunity to testify regarding the draft 
legislation regarding ``Improving the authority for the Secretary of 
Veterans Affairs (VA) to hire and retain physicians and other employees 
of the Department of Veterans Affairs''.
    From the inception of The American Legion's System Worth Saving 
(SWS) Program in 2003, The American Legion has tracked and reported 
staffing shortages at every VA medical facility across the country and 
submitted those to Congress, VA Central Office (VACO), and to the 
President of the United States. Through numerous SWS hospital site 
visits, The American Legion has dedicated considerable resources to 
monitoring the Veterans Health Administration (VHA) healthcare system.
    Unfortunately, there are no easy solutions for VA when it comes to 
effectively and efficiently recruiting and retaining medical staff to 
treat the growing number of veterans that are entering the VA 
healthcare system. The American Legion believes that access to basic 
health care services offered by qualified primary care providers should 
be available locally as often as possible. VHA is still currently 
struggling to achieve the appropriate balance of primary care and 
medical specialists across the country.
    In 2004, The American Legion urged the VA to develop an aggressive 
strategy to recruit, train, and retain advanced practice nurses 
(APN's), registered nurses (RN's), licensed practical nurses (LPN's), 
and nursing assistants (NA's) to meet the inpatient and outpatient 
health care needs of veterans. The Legion fully supports VA's 
education-assistance programs for APNs, RNs, LPNs, and NA's. We also 
urged VA to provide equitable and competitive wages for Advanced 
Practice Nurses (APNs), Registered Nurses (RNs), Licensed Practical 
Nurses (LPNs), and nursing assistants. 1A\2\
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    \2\ 1AResolution No. 237: The American Legion Policy on VA Nurse 
Recruitment and Retention
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    Due to the fact that one out of every three veterans treated by the 
VA lives in a rural area, The American Legion remains concerned with 
the problems rural veterans face due to a lack of access to qualified 
health care. As the number of veterans residing in rural communities 
increases, veterans will continue to struggle to find timely and 
quality VA health care that meets their individual health care needs. 
VA medical centers in rural areas have often expressed concerns in 
recruiting and retaining qualified medical and clinical providers due 
to their inability to compete with medical centers in large 
metropolitan areas. In The American Legion's 2012 System Worth Savings 
(SWS) Report on Rural Healthcare, The American Legion found that:
    ``[Department of Veteran Affairs Medical Centers (VAMCs)] in rural 
America, recruitment and retention of primary and specialty care 
providers has been a constant challenge. Some clinicians prefer to 
practice in more urban settings with more research opportunities and 
quality of life that urban settings provide.'' 1A\3\
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    \3\ 1AThe American Legion: 2012 System Worth Saving Report on Rural 
Health Care
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    In 2014, The American Legion published a SWS report titled ``Past, 
Present, and Future of VA Healthcare'', which noted several challenges 
VA still faced regarding recruiting and retention such as:

     Several VAMCs continue to struggle to fill critical 
leadership positions across multiple departments.
     These gaps have caused communication breakdowns between 
medical center leadership and staff that work within these departments.

    During our 2013 site visit to the Huntington VA Medical Center in 
Huntington, West Virginia, we recommended that, ``VHA conduct a rural 
analysis for hard to recruit areas and look into different options to 
support VAMCs in getting talent they need to better serve veterans.'' 
VHA needs to ensure that veteran health care is consistent across each 
Veterans Integrated Service Network (VISN).
    In 2015, during our SWS site visit to the VA Medical Center in St. 
Cloud, Minnesota, providers expressed concerns about the number of 
physician vacancies, and how the additional workload is impacting 
morale at the medical centers. During the same visit, one veteran 
expressed concern noting ``every time [I] visit the medical center, [I 
am] assigned a new primary care provider because [my] last provider 
either quit or transfer to another VA.''
    There have been numerous reports citing VA's staffing issues, for 
example in January 2015, the VA's Office of Inspector General (VAOIG) 
released their determination of the ``Veterans Health Administration's 
Occupational Staffing Shortages,'' as required by Section 301, of the 
``Veterans Access, Choice and Accountability Act (VACAA) of 2014''. 
With this report, VAOIG determined that the five occupations with the 
largest staffing shortages were Medical Officers, Nurses, Physician 
Assistants, Physical Therapists, and Psychologists. The OIG recommended 
that the ``Interim Under Secretary for Health continue to develop and 
implement staffing models for critical need occupations.'' Ultimately, 
if the VA continues to struggle with retention and recruitment, the 
trend of closures (or continued closures) for multiple departments 
within VAMCs nationwide will continue.
    As The American Legion continues to conduct System Worth Saving 
Site visits across the VA health care system, we see VA staffing 
shortages getting worse rather than improving.
    Draft Legislation to Improve Hiring Practices at the Department of 
Veterans Affairs:
    This draft bill aims to improve the authority for the VA Secretary 
to hire and retain physicians and other employees of the VA. Below is a 
section by section analysis of the draft bill as presented:
    Section 2: Appointment and Pay for Directors of Medical Centers and 
Veterans Integrated
    Services Network (VISN)
    Currently, Paragraph (4) of section 7306(a) of Title 38, United 
States Code (U.S.C.) states that the Office of the Under Secretary for 
Health shall consist of such Medical Directors as may be appointed to 
suit the needs of the Department, who shall be either a qualified 
doctor of medicine or a qualified doctor of dental surgery or dental 
medicine 1A\4\. Subsection (a) of this bill would add ``or other 
qualified medical professionals.''
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    \4\ 1A38 U.S. Code Sec.  7306 : Office of the Under Secretary for 
Health
---------------------------------------------------------------------------
    This subsection includes a new section in Title 38 U.S.C. Chapter 
74, Subchapter IV ``Pay for Nurses and Other Health-Care Personnel.'' 
The new section, titled ``Medical Directors and directors of Veterans 
Integrated Service Networks (VISN),'' discusses elements of pay, base 
pay, market pay, requirements and limitations on total pay, treatment 
of pay, and ancillary effects of decreases in pay.
    The American Legion supports legislation addressing the recruitment 
and retention challenges that the VA has regarding pay disparities 
among those physicians and medical specialists who are providing direct 
health care to our Nation's veterans 1A\5\.
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    \5\ 1AAmerican Legion Resolution No. 101: Department of Veterans 
Affairs Recruitment & Retention-Sept. 2015
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    The American Legion supports this section.
    Section 3: Adjustment of Hours Authorized for Certain Full-Time 
Employees of Veterans Health Administration
    Currently, Section 7423(a) of Title 38, U.S.C., sets the hours of 
employment of Full Time Employees (FTEEs) to not less than 80 hours in 
a biweekly pay period 1A\6\. This section is a legislative request by 
the VA which would allow the Secretary to modify the hours that 
employees work within the Veterans Health Administration by changing 
the regulation to ``be more or less than 80 hours in a biweekly pay 
period if the total hours of employment for such an employee does not 
exceed 2,080 hours per calendar year.''
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    \6\ 1A38 U.S. Code Sec.  7423: Personnel Administration; Full-Time 
Employees-2011
---------------------------------------------------------------------------
    The American Legion encourages and supports VA in providing 
extended hours and weekend appointments for both primary and specialty 
care at all VA medical facilities in addition to their regular hours of 
operation 1A\7\.
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    \7\ 1AResolution No. 251: Extended Hours and Weekends for Veterans' 
Health Care-Aug 2014
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    The American Legion supports this section.
    Section 4: Public-Private Contributions for Additional Educational 
Assistance for
    Graduate Degrees Relating to Mental Health
    This section allows the Secretary to pay 66 percent for the Yellow 
Ribbon Program under the Post-9/11 GI Bill for a graduate degree in the 
mental health field instead of ``up to 50 percent'' as is currently the 
case. The schools would then only be required to pay the remaining 34 
percent as opposed to ``an equal percentage.''
    This increase is not going to apply to all people using the GI. 
Bill, as there are several particular requirements to qualify. In order 
to qualify the veteran would be required to already have a bachelor's 
degree; be eligible for the Post-9/11 GI Bill and eligible for the 
Yellow Ribbon Program; and pursuing the degree with the intention of 
being a mental health professional for VA.
    The Yellow Ribbon Program allows institutions of higher learning 
(i.e., colleges, universities, and other degree-granting schools) in 
the U.S. to voluntarily enter into an agreement with VA to fund tuition 
and fee expenses that exceed the tuition and fee amounts payable under 
the Post-9/11 GI Bill. It is well documented and understood that 
present and future labor shortages are in the healthcare field. It's 
important to note - as the aging U.S. population causes the number of 
working-age adults to shrink - the demand for medical workers will 
certainly increase. Consequently, paired with the often high education 
and experience requirements needed to enter the job market - it has 
been a factor in the shortage in healthcare workers.
    Based upon VA's report, they've determined that the five 
occupations with the largest staffing shortages' were Medical Officer, 
Nurse, Physician Assistant, Physical Therapist, and Psychologist. 
Without question there is a tremendous need for healthcare 
professionals, and something has to be done to deal with this shortage.
    This increase in payment just might provide the right incentive for 
more schools to participate in the Yellow Ribbon Program and more 
student-veterans to potentially pursue employment within the healthcare 
field, which would lead to a greater percentage of potential employees 
in the healthcare industry. The healthcare industry is an attractive 
and high growth industry (includes good pay, benefits and mobility)--
it's a win-win for all of them and the VA.
    The American Legion seeks and supports any legislative or 
administrative proposal that improves, but not limited to the GI bill, 
Department of Defense Tuition Assistance (TA), Higher Education Title 
IV funding (i.e., Pell Grants, Student Loans, etc) and education 
benefits so servicemembers, veterans, and their families can maximize 
its usage. 1A\8\
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    \8\ 1AResolution 312: Ensuring the Quality of Servicemember and 
Veteran Student's Education at Institutions of Higher Learning- Aug. 
2014
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    The American Legion supports this section.
    Section 5: Modification to Annual Determination of Staffing 
Shortages in Veterans Health Administration
    Currently, subsection (a) of section 7412 of title 38 U.S.C. 
requires the Secretary to publish in the Federal Register, the five 
occupations of personnel of this title of the Department covered under 
section 7401 of this title for which there are the largest staffing 
shortages throughout the Department as calculated over the five-year 
period preceding the determination 1A\9\. This section would modify the 
Veterans Access, Choice and Accountability Act, (VACAA) which required 
the VA Office of Inspector General (VAOIG) on an annual basis to 
determine the five occupations that have the highest staffing 
shortages. The VAOIG would now be required to conduct a review to 
evaluate staffing shortages within five clinical and nonclinical fields 
within each Veterans Service Integrated Networks (VISNs).
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    \9\ 1A38 U.S. code Sec.  7412: Annual determination of staffing 
shortages; recruitment and appointment for needed occupations-March 
2016
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    The American Legion encourages and supports the VHA leadership to 
conduct an internal review and develop an action plan to address VISN 
management, staffing and its current geographic boundaries/catchment 
areas for the purpose of providing veterans better and timely access to 
quality health care. 1A\10\
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    \10\ 1AResolution 114: Department of Veterans Affairs Veteran 
Integrated Service Networks-Aug. 2014
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    The American Legion supports this section.
    Section 6: Repeal of Compensation Panels to Determine Market Pay 
for Physicians
    and Dentists
    This section would replace subsection (c) paragraph (4) of Section 
7431, Title 38 U.S.C. Paragraph (4) which determines the amount of 
market pay for physicians or dentists, with a system that would require 
the Secretary consult two or more national surveys of pay for 
physicians or dentists, as applicable, whether prepared by private, 
public, or quasi-public entities in order to make a general assessment 
of the range of pays payable to physicians or dentists. It also 
requires the Secretary to consult with and consider the recommendations 
of an appropriate panel or board composed of physicians or dentists.
    The American Legion currently does not have a position on Section 
6.
    Section 7: Executive Management Fellowship Program
    This would require the Secretary to select, each year, at least 18 
but not more than 30 eligible Veterans Benefits Administration (VBA) 
and Veterans Health Administration (VHA) employees to participate in a 
one year fellowship with a private sector company or entity.
    As it currently stands, VA has over half of their critical 
leadership positions either unfilled or filled in an interim role. 
Sending a portion of the workforce out of VA every year would only 
exacerbate this situation. If VA can afford to lose these personnel for 
an entire year then they don't need that position. The American Legion 
would rather see VA fill the positions they have and ensure there is a 
full workforce available to treat the needs of veterans.
    The American Legion opposes this section.
    Section 8: Accountability of Leaders for Managing the Department of 
Veterans Affairs
    The VA has come under scrutiny by Congress, Veterans Service 
Organizations (VSOs), media, veterans, and the American public for 
their failures in leadership performance and accountability which 
resulted in numerous quality and patient safety issues, as well as 
patient deaths.
    This section would add a new section following Chapter 7 of title 
38, U.S.C.'s section 709 pertaining to Employment Restrictions. The new 
section, ``Annual Performance Plan for Political Appointees,'' requires 
the Secretary to conduct an annual performance plan for each political 
appointee of the Department that is similar to the annual performance 
plan conducted for an employee of the Department who is appointed as a 
career appointee within the Senior Executive Service at the Department. 
This assessment would ensure the employee is meeting their goals with 
recruiting, engaging and motivating employees, training employees, and 
holding each employee accountable for performance issues.
    The American Legion urges Congress to enact legislation that 
provides the VA Secretary the authority to remove any individual from 
the Senior Executive Service (SES) due to performance and transfer 
those individuals to a General Schedule (GS) position without any 
increased monetary benefit. 1A\11\
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    \11\ 1AResolution No. 30: Department of Veterans Affairs 
Accountability- May 2015
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    The American Legion supports this section.
    Section 9: Modification to Veterans Preference
    Veterans' preference is authorized by the Veterans' Preference Act 
(VPA) of 1944; it only applies to federal government employment. It 
provides that most veterans are to receive an extra five points (ten 
points for disabled veterans) in receiving and keeping federal jobs. 
The Veterans' Employment Opportunity Act (VEOA) of 1998 extended 
certain rights and remedies to recently separated veterans. A grateful 
nation created veterans' preference to ensure fair treatment for those 
citizens who served this country in the Armed Forces. The following 
recommendations are:

    c IChange the service requirements to receive veterans' preference 
for Reservists and Guardsmen from 180 days of consecutive active-duty 
service to 180 days of cumulative active-duty service.

    Based upon the high percentage of Reservists and Guardsmen that 
have honorably served as well as been deployed multiple times in the 
war against terror - their days of service should merit inclusion 
within veterans' preference criteria for 180 days of cumulative 
service.

    c IExpand those to be considered ``preference eligible'' to include 
all retired service members, including those who retire above the rank 
of major or its equivalent.

    In addition, approximately 250,000 service members leave the Armed 
Forces every year, of which 6.4 percent are Officers O 094 and above 
(6.4 percent equates to roughly 16,000 Officers O 094 and above). 
America shouldn't overlook the minority of high ranking officers who 
are ready to start a second career in public service. The lessons 
learned in the Armed Forces allow these individuals to provide a 
quality level of professionalism, expertise and patriotism within the 
structure of a federal agency who's seeking that kind of talent.

    c IExpand veterans' preference to also apply to hiring individuals 
for the Senior Executive Service at VA.

    The attributes that define a veteran employee, which include a 
strong work ethic, adaptability, organizational skills, team player, 
self-confidence, preparedness - are all things a leader needs to have 
in abundance. It only seems fitting that veterans applying for a Senior 
Executive Service position would receive veterans' preference.
    Lastly, veterans' preference should play a large role in employing 
veterans and their spouses. Federal agencies need to make sure that 
their Human Resource personnel are properly trained to effectively 
implement veterans' preference. The federal government has scores of 
employment opportunities that educated, well-trained, and motivated 
veterans can fill given a fair and equitable chance to compete. Working 
together, all federal agencies should identify those vocational fields, 
especially those with high turnover rates, for transitioning veterans 
who are trying to continue their service within the federal government.
    The American Legion restates its commitment to ensure that veteran 
preference is consistently and accurately applied in federal civilian 
recruitment, application, and hiring 1A\12\.
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    \12\ 1AResolution 301- Enforcing Veterans' Preference Hiring 
Practices in Federal Civil Service: Aug 2014
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    The American Legion supports this section.
    Section 10: Reemployment of Former Employees
    This section would allow the Secretary to noncompetitively 
reappoint a qualified former employee to any position within the VA as 
long as the position is not more than one grade higher than what they 
received in their former position and as long as if they employee left 
VA voluntarily within the prior two years and has kept all licensures 
and credentials up to date.
    The American Legion currently has no position on Section 10.
    Section 11: Recruiting Database
    This section would require the Secretary of VA to establish a 
single centralized database that lists all critical vacancies that are 
difficult to fill within VA. This database would contain information on 
qualified individuals who have applied previously for other positions 
within VA in which they have not been selected however, would be 
qualified for another position within VA. The Secretary would be 
required to use this database to consider qualified applicants who have 
already applied for other positions within VA to fill prolonged 
vacancies.
    The American Legion urges the VHA to continue to develop and 
implement staffing models for critical need occupations. 1A\13\
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    \13\ 1AResolution 101- Department of Veterans Affairs Recruitment 
and Retention: Sept. 2015
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    The American Legion supports this section.
    Section 12: Human Resources Academy
    This section would require Human Resources (HR) professionals 
within VA be trained in hiring Title 38 employees within VHA. These 
professionals will be adequately trained on how to best recruit and 
retain employees in VHA.
    The American Legion currently has no position on Section 12.
    Section 13: Promotional Opportunities for Technical Expert
    This section would require the Secretary to establish a promotional 
track system for employees of the VA for technical experts without 
requiring them to take managerial positions if they choose to stay 
employed at VA.
    The American Legion currently has no position on Section 13.
    Section 14: Comptroller General Study on Succession Planning
    This section would require the VA Comptroller General to conduct a 
succession planning study at each VA Medical Center (VAMC), Regional 
Office (RO), and National Cemetery (NCA). While The American Legion 
supports studies on VHA staffing, we currently do not have a position 
on staffing at the VARO's or at NCA.
    The American Legion encourages and supports the VHA leadership to 
conduct an internal review and develop an action plan to address VISN 
management, staffing and its current geographic boundaries/catchment 
areas for the purpose of providing veterans better and timely access to 
quality health care. 1A\14\
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    \14\ 1AResolution 114: Department of Veterans Affairs Veteran 
Integrated Service Networks- Aug. 2014
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    The American Legion supports this section.
    Section 15: Information on Hiring Effectiveness
    This section requires VA to measure and collect certain information 
regarding hiring effectiveness. The American Legion continues to be 
concerned VA's hiring process is cumbersome and negatively affects 
VHA's ability to recruit and retain effective staffing levels in order 
to meet veteran's overall health care needs.
    The American Legion urges the VHA continue to develop and implement 
staffing models for critical need occupations and that VA work more 
comprehensively with community partners when struggling to fill 
shortages within VA's ranks. 1A\15\
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    \15\ 1AResolution 101:Department of Veterans Affairs Recruitment 
and Retention- Sept. 2015
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    The American Legion supports this section.
    Section 16: Employment of Students and Recent Graduates
    This section requires VA to promulgate regulations to allow for 
excepted service appointments of students and recent graduates leading 
to conversion to career or career conditional employment of a student 
or recent graduate.
    The American Legion has no position on Section 16.
    Section 17: Exit Surveys
    This section requires VA to request that employees voluntarily 
leaving VA service complete standardized exit surveys.
    The American Legion has no position on this section.
    Conclusion
    The American Legion understands that filling highly skilled 
vacancies at premiere VA hospitals around the country is challenging. 
We also expect VA to do whatever legally permissible to ensure that 
veterans have access to the quality healthcare they have come to expect 
from VA. VA leadership needs to do more to work with community members 
and stakeholders.
    Except as noted above, on balance there is a large amount of this 
proposed legislation which would have a positive effect on transforming 
VA to a more effective healthcare delivery system.
    As always, The American Legion thanks the Subcommittees on Health 
and Economic Opportunity for the opportunity to explain the position of 
the over 2 million veteran members of this organization.
    For additional information regarding this testimony, please contact 
Mr. Warren J. Goldstein at The American Legion's Legislative Division 
at (202) 861 092700 or [email protected]

                                 
                  Prepared Statement of Carlos Fuentes
    Chairmen Benishek and Wenstrup, Ranking Members Brownley and Takano 
and members of the Subcommittees, on behalf of the men and women of the 
Veterans of Foreign Wars of the United States (VFW) and our 
Auxiliaries, I want to thank you for the opportunity to present the 
VFW's views on ways the Department of Veterans Affairs (VA) can improve 
recruitment and retention of high quality health care professionals and 
other employees.
    The VFW thanks you for recognizing that VA's ability to hire and 
retain high quality employees is equality as important as its ability 
to fire or demote employees who put veterans' lives at risk. The VFW 
agrees with many of the ideas included in the draft legislation being 
discussed today. However, we would like to share an idea that we hope 
the Subcommittees will consider.

Expedited Authority to Hire Frontline Health Care Staff

    During our site visits of VA medical facilities, the VFW has 
noticed one constant struggle facilities face--hiring and retaining 
entry level clerks who help with answering phones, greeting patients, 
scheduling appointments, and other administrative tasks. During our 
visits, we often hear providers and facility leadership say that the 
lack of administrative support staff limits their ability to deliver 
health care to veterans, particularly when operating in a patient 
aligned care team (PACT) where team members are often left to backfill 
the duties of vacant positions. This contributes to attrition of 
existing employees who are overworked and underpaid because of 
vacancies that take too long to fill. Non-clinical VA employees, 
including frontline staff, are typically hired under title 5, United 
States Code (U.S.C.) authorities. Unfortunately, such authorities 
preclude VA from expeditiously hiring qualified candidates to fill 
vacancies.
    Under section 7802 of title 38, U.S.C., the VA Canteen Service is 
exempted from title 5, U.S.C., competitive service, general schedule 
pay rates and classification requirements to ensure it is able to 
provide veterans reasonably priced merchandise and services essential 
to their comfort and well-being. Similar to VA medical facilities, the 
Canteen Service relies on entry level employees to operate and maintain 
its services. However, without the exemptions from competitive service 
requirements, the VA Canteen Service would not be able to operate its 
retail stores, cafes, and quality of life programs in VA medical 
facilities around the country.
    The VA Canteen Service has the authority to bypass the USA Jobs 
process and hire employees through referral and traditional job search 
engines such as Monster, Indeed, and Career Builder. When it finds 
qualified candidates, the VA Canteen Service hires employees as 
contractors while they undergo the 30 0960 day process to become a 
federal employee. This process provides the VA Canteen Service the 
latitude it needs to ensure its retail stores remain fully staffed 
despite high turnover rates. The VFW urges Congress to provide the 
Veterans Health Administration (VHA) similar authorities to quickly 
hire into high turnover positions at VA medical facilities.

Discussion Draft to improve the authority of the Secretary of Veterans 
    Affairs to hire and retain physicians and other employees.

    The VFW strongly supports efforts to expand VA's authorities to 
hire and retain high quality employees. This legislation takes a 
multifaceted approach towards achieving that goal. The VFW supports 
sections 2, 3, 5, 7, 8, 12, 14, 15, 16 and 17; does not oppose sections 
6, 10, 11 and 13; has concerns with section 9; and opposes section 4.
    Section 2 would ensure VA has the authority to properly compensate 
medical center directors. The VFW generally supports this section and 
has two recommendations to improve it. Director positions are hard to 
fill positions because they are responsible for overseeing hundreds of 
employees delivering care and services to thousands of beneficiaries. 
Such a charge requires proper incentives, such as market-based 
compensation, which this legislation would address.
    However, VA must also have the leeway to quickly hire a qualified 
candidate when one is identified. The best qualified person for a 
medical center position may not be searching for a job on USA Jobs, and 
if VA identifies a qualified candidate it should not be required to 
have that candidate apply for an opening through USA Jobs. This 
legislation would also preclude directors from appealing a decrease in 
pay resulting from an involuntary reassignment in connection with a 
disciplinary action. While the VFW fully supports the reduction in pay 
of VA employees who have committed malfeasants, we believe such 
individuals have the right to due process. For that reason, we suggest 
the Subcommittees clarify that the reduction in pay is final after the 
employee has been offered the opportunity to appeal the disciplinary 
action.
    The VFW supports section 3, which would grant VA health care 
providers the ability to have flexible working hours that best suit the 
demand for health care by the veterans they serve. In response to the 
access crisis, VA has made a full-fledged effort to increase access for 
veterans who rely on VA for their health care needs. In the past year, 
VHA has increased clinic production by 10 percent, adopted best 
practices from the private sector, and increased the number of health 
care employees by more than 14,000. Yet, VA continues to face numerous 
challenges in meeting the growing demand on its health care system. One 
of those challenges is the statutory 40-hour work week limitation for 
title 38, U.S.C., employees. The VFW supports efforts to eliminate this 
access barrier and improve VA's ability to recruit and retain high 
quality health care professionals.
    The VFW opposes section 4, which would amend the Yellow Ribbon 
Program to require VA to cover up to 66 percent of the full cost of an 
advanced degree in mental health care. The VFW is a strong advocate and 
proponent of the Yellow Ribbon Program and the Post-9/11 Educational 
Assistance Act, commonly referred to as the Post-9/11 G.I. Bill. The 
VFW also supports efforts to provide additional assistance for veterans 
who choose to advance their careers by obtaining a graduate or doctoral 
degree in mental health care. However, the VFW does not believe 
amending the Yellow Ribbon Program is the best option to do so.
    The Yellow Ribbon Program was established to address the gap 
between the cost of tuition and fees associated with approved degree 
programs and the amount VA is statutorily able to cover under the Post-
9/11 G.I. Bill. To supplement the Post-9/11 G.I. Bill, VA is authorized 
to enter into an agreement with educational institutions to cover up to 
fifty percent of such gaps, which may be up to tens of thousands of 
dollars. While the VFW agrees that increasing the percentage VA is 
statutorily authorized to cover under the Yellow Ribbon Program would 
incentivize educational institutions to establish Yellow Ribbon 
agreements with VA, it does not provide much incentive for veterans to 
obtain degrees in mental health care.
    Furthermore, the discussion draft fails to ensure veterans have 
enough Post-9/11 G.I. Bill eligibility to complete their degree 
program. This is a particular concern for veterans who use their Post-
9/11 G.I. Bill benefits to obtain a bachelor's degree and would like to 
participate in this program. Given that the Post-9/11 G.I. Bill is 
limited to 36 months of eligibility, it is unlikely that these veterans 
would have enough eligibility remaining to complete an advanced degree 
in mental health.
    The VFW is a proponent of public-private partnerships, but believes 
this program would be better suited under VA's Health Professionals 
Educational Assistance Program (HPEAP). VA operates six different 
educational assistance programs under its HPEAP authorities, including 
a debt reduction program and several employee scholarships. One of 
those programs is the Visual Impairment Education Assistance Program, 
which was created by Public Law 111 09163, the Caregivers and Veterans 
Omnibus Health Services Act of 2010, to increase the supply of 
qualified blind rehabilitation specialists for the department and the 
nation.
    This program authorizes VA to provide any person enrolled in a 
degree or certificate program in visual impairment or orientation and 
mobility up to $45,000 to complete their educational program if they 
agree to serve as a full time VA employee after completing such 
program. The VFW urges Congress to consider a similar program that 
would authorize VA to cover the cost of a veteran's advanced mental 
health care degree, up to the post-9/11 G.I. Bill rate, for veterans 
who agree to serve as a VA mental health care professional.
    Section 9 would amend veterans preference to ensure veterans who 
served in the Guard and Reserves are afforded the same hiring 
preferences as their active duty counterparts. Currently, veterans who 
served after September 11, 2001, are required to have served at least 
180 consecutive days on active duty. Due to our all-volunteer military 
and the nature of the wars in Iraq and Afghanistan, the Guard and 
Reserves have been utilized much more than they have during past 
conflicts. However, not all Guard and Reserves service members receive 
active duty orders for more than 180 days. Thus, many veterans that 
deployed into harm's way in support of the wars in Iraq and Afghanistan 
are not eligible for veterans hiring preferences. The VFW supports 
correcting this inequity.
    Section 9 would require VA to comply with title 5 competitive 
service requirements when hiring Senior Executive Service (SES) 
employees. While the VFW supports applying veterans preference to the 
employment process for VA SES employees, we feel that Congress must 
streamline, not impede, VA's ability to hire qualified executives. That 
is why we recommend that the Subcommittees amend this section to exempt 
VA's SES employment process from title 5 competitive service 
requirement. To ensure VA hires qualified veterans as senior 
executives, Congress should amend title 38 to ensure VA properly 
considers veterans when hiring SES employees.
    Mr. Chairman, this concludes my testimony and I will be happy to 
answer any questions you or the Subcommittee members may have.
 Information Required by Rule XI2(g)(4) of the House of Representatives
    Pursuant to Rule XI2(g)(4) of the House of Representatives, the VFW 
has not received any federal grants in Fiscal Year 2016, nor has it 
received any federal grants in the two previous Fiscal Years.
    The VFW has not received payments or contracts from any foreign 
governments in the current year or preceding two calendar years.

                                 
               Prepared Statement of Carolyn Clancy, M.D.
    Good morning Chairman Benishek, Chairman Wenstrup, Ranking Member 
Brownley, Ranking Member Takano, and Members of the Committee. Thank 
you for inviting us here today to present our views on the draft bill 
to improve the authority of the Secretary of Veterans Affairs to hire 
and retain physicians and other employees of the Department of Veterans 
Affairs, and for other purposes. Joining me today is Elias Hernandez, 
Chief Officer, Workforce Management and Consulting; Tia N. Butler, 
Executive Director, Corporate Senior Executive Management Office; and 
Kimberly P. McLeod, Associate Chief Counsel.
    We are pleased to see the Committee include in the draft 
legislation, three of our legislative proposals which will give us the 
necessary resources to meet the Department of Veterans Affairs' (VA) 
obligation to provide timely, quality health care and benefits to 
Veterans. Due to the timing of the hearing, the VA is unable to provide 
views for sections 7, 9, 10, 11, 12, 15, 16, 17 as well as costs for 
section 4. These are currently being drafted and we will forward the 
remaining views and costs to you as soon as they are available.

Section 2, Appointment and pay for directors of medical centers and 
    Veterans Integrated Services Networks

    VA supports section 2 as the provision matches a proposal put 
forward in February 2016 in VA's Fiscal Year 2017 budget submission. VA 
believes that there are three primary factors that warrant a separate 
compensation system for Medical Directors and VISN Directors. First, 
existing pay compression within the current Senior Executive Service 
(SES) pay system and the closely proximate rates of pay for direct 
reports to Medical Center Directors and VISN Directors have resulted in 
declining Director applicant pools. Second, a high number of existing 
(an estimated 84 percent by FY 2018) Directors are or will soon be 
eligible for retirement. Third, private sector pay for health care 
leadership positions is highly competitive.
    In addition, there are limited pay incentives for experienced 
Medical Center Directors and VISN Directors to voluntarily move to fill 
more demanding positions. Due to the SES pay compression between 
experienced Medical Center Directors and VISN Directors, the small pay 
raise, if any, that VHA is able to offer in a reassignment may cause 
the candidate to be disadvantaged financially. The most significant 
cost disparities occur due to housing costs and in some cases, higher 
tax rates (e.g., New York, California). With current executive pay 
authorities, a move for the good of the organization most of the time 
means a move to the financial detriment of Directors and their 
families. On average, it has taken over 6 months to fill Medical Center 
Director and VISN Director positions, with many being re-announced 
multiple times for positions in both rural and major metropolitan 
areas. The reluctance on the part of these senior leaders to relocate 
is understandable. It is imperative that VHA have the ability to 
implement pay to retain eligible leaders, reward mobility, and ensure 
knowledge transfer to the next generation of Medical Center Directors 
and VISN Directors. VA would request, however, that the section stating 
that the Medical Director and VISN Directors be a qualified doctor of 
any kind be removed from the bill. It is already difficult to recruit 
for these positions. This additional restriction would make it nearly 
impossible in some areas. VA estimates that enactment of section 2 
would cost $8.8 million in FY 2017, $46 million over 5 years, and $93.2 
million over 10 years.

Section 3, Adjustment of hours authorized for certain full-time 
    employees of Veterans Health Administration

    Section 3 would allow VA to arrange flexible physician and 
physician assistant work schedules to allow for the hiring and full 
implementation of a hospitalist physician system and to accommodate the 
unusual work schedule requirements for Emergency Medicine (EM) 
Physicians.
    VA supports increased flexibility for critical medical personnel. 
Hospitalist physicians and EM physicians specialize in the care of 
patients in the hospital, often working irregular work schedules to 
accommodate the need for continuity of efficient hospital care. VA 
believes that increased scheduling flexibility would align VA practice 
with the private sector, facilitating the recruitment, retention of 
emergency physicians and the recruitment, retention and operation of a 
hospitalist physician system at VA medical centers (VAMC). We 
understand that the Office of Personnel Management has some concerns 
with respect to certain of the bill's provisions. The Administration 
looks forward to working with the Congress and our agency partners to 
finalize language on these provisions. VA would request the language in 
section 3 (2) include the language of, ``is not less than'' in place of 
``does not exceed''.
    VA believes section 3 would be cost neutral in terms of impact on 
salaries as it merely authorizes flexibility in physician and physician 
assistant work schedules to allow for the hiring and full 
implementation of a hospitalist physician system and improvements in EM 
physician coverage and enhanced ability to recruit EM trained and 
experienced physicians.
    LRD

Section 4, Public-private contributions for additional educational 
    assistance for graduate degrees relating to mental health

    Section 4 of the bill would also amend current section 3319 of 
title 38 to prohibit the use of transferred entitlement under the new 
program. If enacted, the amendments made by section 4 would apply to a 
quarter, semester, or term that begins on or after July 1, 2017.
    VA supports legislation that would provide training and employment 
opportunities for Veterans; however, the Department has some concerns 
with this section of the bill. VA is not certain a change in the way VA 
and IHLs share contributions for specific degrees and programs would be 
beneficial. Under its current structure, the Yellow Ribbon Program is a 
remarkably successful program with nearly 2,000 participating 
institutions. During FY 2015, 49,905 students were beneficiaries of the 
program.
    In order to implement section 4, VA would have to identify Post-9/
11 GI Bill Veterans who are currently pursuing an advanced degree in 
mental health, determine their eligibility for the new program, and 
verify that each Veteran intends to seek employment with VA. This would 
create a significant administrative burden as the Long Term Solution 
(LTS), the system used to process Post-9/11 GI Bill payments, does not 
have the capability to issue varying Yellow Ribbon payments based on 
the type of program being pursued. Subject to the availability of 
funding, VA would need one year from the date of enactment to make 
programming changes to the LTS to support implementation of this 
section. In addition to LTS changes, the amendments made by section 4 
would also require changes to the Comparison Tool, VA Online 
Certification of Enrollment (VA ONCE), and Web Enabled Approval 
Management (WEAMS) computer systems. Otherwise, manual processes would 
be required, which would result in a decrease in timeliness and 
accuracy for processing GI Bill claims.
    Further, the amendments made by section 4 would authorize VA to 
establish residencies and internships at VA medical facilities for 
Veterans participating in the program. VHA has already established 
training programs in mental health disciplines in many locations. These 
programs lead to a degree, licensure, certification, or registration. 
The process to develop training programs requires relationships with 
accredited educational sponsors and suitable infrastructure for the 
training program, including space, qualified faculty preceptors, 
information technology (IT) equipment, staff support, and a sufficient 
number of patients to satisfy the needs of the educational program. 
Therefore, establishing residencies and internships must occur in 
settings with appropriate infrastructure and collaborative educational 
partnerships.
    This bill also does not address the unique qualification standards 
of each of the professions that are listed in the bill. Each of the 14 
professions/disciplines listed has unique qualification standards which 
must be met to be eligible for VA employment. For some of these 
professions (e.g. psychologist, social worker, mental health nurse, 
marriage and family therapist), the qualification standards include 
both educational accreditation as well as licensure requirements. Other 
professions listed (e.g. addiction therapist, vocational rehabilitation 
therapist) do not have educational or licensure requirements.
    The Yellow Ribbon Education program allows for Veterans to attend 
mental health programs that do not meet the accreditation standards 
required in the VA qualification standards. Thus, if an individual 
obtained a degree in those programs, that individual would not be 
eligible for VA employment.
    For VA to support this bill, each of the professions listed that 
has educational/licensure requirements would need to have a provision 
that would state that the program meets the educational requirements 
defined by the VA qualification standards. Additionally, for some of 
the professions listed, even with such a provision, it may not be 
possible to guarantee VA employment (even if the educational 
requirements of the profession are met). For example, the Psychology 
Qualification Standards require that an individual have graduated from 
a program accredited by the American Psychological Association (APA) as 
well as have completed an internship accredited by APA. While the bill 
suggests that the Secretary may establish residencies and internships 
at medical facilities of the Department, the Secretary is not able to 
accredit these internships.
    VA is still determining costs associated with this provision.

Section 5, Modification to annual determination of staffing shortages 
    in Veterans Health Administration

    Section 5, would amend 38 USC Sec. 7412 (a) to require the 
Inspector General of the Department of Veterans Affairs (VAOIG) to 
determine and the Secretary of Veterans Affair to publish in the 
Federal Register, the five clinical occupations and the five 
nonclinical occupations of personnel of the Department covered under 
section 7401 for which there are the largest staffing shortages with 
respect to each Veterans Integrated Services Network (VISN) as 
calculated over the five-year period preceding the determination.
    The VA defers to VAOIG on how they would process this report.

Section 6, Repeal of compensation panels to determine market pay for 
    physicians and dentists

    Section 6 would modify 38 USC Sec.  7431 to eliminate the 
compensation panel recommendation process required under 38 USC 
Sec. 7431(c)(4)(B).
    VA supports this section as it is similar to another proposal put 
forward in February 2016 in VA's Fiscal Year 2017 budget submission. 
The ``Department of Veterans Affairs Health Care Personnel Enhancement 
Act of 2004'' (Public Law 108 09445, dated December 3, 2004) 
established the current pay system for Veterans Health Administration 
(VHA) physicians and dentists. A requirement of the pay system that has 
proven to be of little or no value is the compensation panel process.
    The current statute requires that the recommendations of a panel 
composed of physicians or dentists be considered when determining the 
amount of market pay for a physician or dentist. To the extent 
practicable, the panel must consist of physicians or dentists (as 
applicable) who are practicing clinicians and who do not hold 
management positions at the medical facility at which the physician or 
dentist subject to the consultation is employed. In most circumstances, 
this requires physicians or dentists to take time away from providing 
direct patient care in order to perform the unnecessary administrative 
function of recommending the amount of pay for prospective employees.
    The compensation panel process is time consuming and adds no value 
as Medical Center Directors and/or other approving officials have the 
authority to approve (decide) the final rate of pay. Currently there 
are three separate reviews being conducted for VHA physicians and 
dentists prior to their appointment, to include: (1) a Professional 
Standards Board reviews the qualifications standards and makes a 
recommendation to appoint an individual tentatively selected for a 
position; (2) the compensation panel recommends market pay and annual 
salary for the provider; and (3) the Medical Staff credentialing and 
privileging committee reviews the provider's credentials and recommends 
medical staff clinical privileges.
    As an example, a compensation panel may be required to convene to 
make a salary recommendation for two prospective physician candidates. 
At a minimum, three physicians would be required to meet to review a 
recommendation made by the selecting official or Chief of Staff, and 
complete the Compensation Panel review form. Using an average salary 
for a VA physician of $218,237 (or $104.92 per hour) in manpower hours 
it would cost $52.46 per 30 minutes x 3 physicians, or approximately 
$157 per compensation panel.
    This may seem like a trivial amount but if you consider the number 
of times each medical center convenes a compensation panel, multiplied 
by the number of VA facilities across the country, the manpower cost of 
this administrative function is much more significant. In VA facilities 
with numerous physician and dentist vacancies, compensation panel 
members may be required to spend many hours a week meeting to 
deliberate and recommend salary for prospective employees. Market pay 
criteria and documentation on the Compensation Panel Recommendation and 
Approval form, VA Form 10 090432a, is time consuming and continues to 
be a challenge for clinicians.
    This arduous process also contributes to a delay in hiring. A VA 
facility is often unable to convene a Compensation Panel on a timely 
basis because its members are unable to quickly meet due to patient 
care responsibilities. Physicians and dentists typically will not 
accept employment or give notice without a firm salary offer, and in 
cases where Compensation Panels are delayed, it pushes back the 
starting dates of new providers which also negatively impacts patient 
care.
    It would be more cost effective and time efficient to allow a 
selecting official and/or Chief of Staff to recommend to the facility 
director the appropriate salary for prospective employees and eliminate 
the compensation panel process.
    The VA believes this proposal to be cost neutral. Physicians and 
dentists will continue to be paid rates approved by the appointing 
official. This proposal will benefit VA by streamlining the appointment 
process.

Section 8, Accountability of leaders for managing the Department of 
    Veterans Affairs

    Section 8 would amend chapter 7 of Title 38 by adding in a new 
section 709A, which would require the Secretary to annually assess the 
performance of political appointees in a manner similar to the 
assessment of career Senior Executive Service employees.

Section 13, Promotional opportunities for technical experts

    Section 13 would require VA to develop a promotional track, which 
does not involve a transition to a management position, for employees 
who are considered technical experts. VA is committed to ensuring that 
its employees are allowed to advance in their careers, regardless of 
whether the employee wants to be a manager. Consequently, VA supports 
this section.

Section 14, Comptroller General study on succession planning

    Section 14 would require the Comptroller General to conduct a study 
on the succession planning at each medical facility of the Department 
of Veterans Affairs, the Veterans Benefits Administration and the 
National Cemetery Administration and submit it to the House and Senate 
Veterans' Affairs Committees not later than one year after the date of 
enactment of this Act.
    The study would include: a determination of the mission-critical 
positions within the entity and the vacancy risk of such positions; an 
analysis of the future needs for mission-critical positions and gaps 
within the existing talent poll of the entity; a description of 
strategies to close skill gaps through the use of training for existing 
staff, targeted recruitment, and hiring; a plan to regularly evaluate 
progress of staff and update existing succession plans using clear and 
measureable metrics and benchmarks; a demonstration of the capacity of 
the entity to execute succession plans with successful succession 
management strategies; and any other matters Comptroller General 
determines appropriate.
    VA defers to GAO.
    Mr. Chairman, this concludes my statement. Thank you for the 
opportunity to appear before you today. We would be pleased to respond 
to questions you or other members may have.

                                 
                       Statements For The Record

              AMERICAN FEDERATION OF GOVERNMENT EMPLOYEES
    Overview: AFGE strongly objects to Section 6 of this draft bill. It 
would destroy the critical market pay process established through 
strong bipartisan support twelve years ago when Congress enacted P.L. 
108 09445 to ensure that VA provider pay would be competitive with 
other health care systems. More specifically, this bill would devastate 
the Department's ability to recruit and retain physicians and dentists 
through:

    u IElimination of the requirement that the Secretary consult two 
pay surveys;
    u IElimination of the requirement that the Secretary consider the 
recommendations of a panel of peers; and,
    u IReturn of all market pay determinations to full Secretary 
discretion.

    The VA desperately needs stronger market pay requirements, not a 
market pay process completely subject to Secretary discretion. 
Currently, the VA is losing large numbers of physicians and dentists 
because of broken pay policies, including: managers who pay new hires 
$20,000 or more than incumbents; managers who make pay promises to new 
hires that they break once the provider is on board; management's 
refusal to convene market pay panels every two years; and improper pay 
panel composition.
    This provision would vastly increase the use of arbitrary pay 
policies against front-line providers in order to further management 
cronyism, discrimination against older physicians and other targeted 
groups and retaliation against vocal providers. The mean-spirited and 
arbitrary nature of this provision makes even less sense given that it 
appears to eliminate an important right for one group of providers 
while giving that identical right to VA directors!

Analysis of other sections:

    Section 2(a): This subsection would expand eligibility for medical 
center director (MC) and Veterans Integrated Service Networks (VISN) 
director appointments to all qualified medical professionals. AFGE 
supports.

    Section 2(b):

    u IThis subsection would extend part of the existing market pay 
process to MC and VISN directors. AFGE supports consideration of 
recruitment and retention needs for setting market pay for these 
positions and the requirement to adjust pay every two years. However, 
AFGE strongly recommends greater transparency in all market pay-setting 
processes (directors, and management and non-management physicians and 
dentists). More specifically, all employees and their representatives 
should have the same rights to request copies of survey data as was 
afforded to registered nurses by Section 601(j) of the Caregiver Act.
    u ISimilarly, all employees whose market pay is set by pay panels 
(which does not apply to directors under this bill) should have the 
right to request information about the composition of their panels.
    u IFrequency of market pay adjustments: Noncompliance with the 
current requirement to make market pay adjustments at least every two 
years is rampant. Directors are far more likely to get timely 
adjustments under this bill than front-line healthcare providers. 
Therefore, AFGE strongly urges the Committee to ensure that managers be 
held accountable for delays in convening market pay panels and 
implementing pay adjustments through performance measures and new 
requirements to report market pay adjustments to Congress. In addition, 
physicians and dentists deserve equal bargaining rights so they can 
challenge unfair and illegal pay practices. Therefore, AFGE urges the 
Committee to approve H.R. 2193, introduced by Representative Mark 
Takano (D 09CA). H.R. 2193 is a valuable recruitment and retention bill 
because it also equalizes rights to bargain over indirect patient care 
matters such as scheduling and assignments.
    u IPay decreases: This provision would deny directors all rights to 
appeal pay decreases. AFGE strongly opposes this provision. Such broad 
Secretary discretion will encourage abuse of discretion by officials 
seeking to harass, discriminate and conduct de facto terminations. 
Under current law, management and non-management physicians and 
dentists are protected to some extent against arbitrary market pay 
decreases as long as they stay in the same position. However, as 
already noted, non-management physicians and dentists have very little 
actual ability to challenge unfair and illegal pay actions because of 
unequal bargaining rights.

    Section 3: This provision would provide flexible work schedules for 
most ``pure Title 38'' personnel. AFGE supports this provision. AFGE 
again urges passage of H.R. 2193 to ensure that every VA employee has 
an equal right to challenge unfair management practices related to 
schedules, assignment and other routine workplace matters.
    Section 4: No comment.
    Section 5: This provision would expand the annual staffing shortage 
determinations to include nonclinical occupations. AFGE supports.
    Section 7: This provision would place Veterans Health 
Administration (VHA) and Veterans Benefits Administration (VBA) 
employees in private-sector executive management fellow programs. AFGE 
strongly opposes this provision. This is likely to be a costly program 
of little value. The skills required to be effective in the VBA and VHA 
workplace must be learned in-house using strong in-house mentors with 
sufficient time and skills, not private sector managers who have no 
experience with the VA's unique population, or its unique health care 
system and benefits programs.
    Section 8: This provision would establish an annual performance 
plan for political appointees. AFGE supports.
    Section 9: This provision makes it easier for reservists to earn 
veterans' preference by counting cumulative service. AFGE supports.
    Section 10: This provision allows for noncompetitive appointments 
with significant pay increases for returning employees, subject to full 
Secretary discretion. AFGE strongly opposes this provision. Upper 
management is very likely to abuse this hiring authority to hire their 
own friends and pass over other qualified applicants using the 
competitive process. In addition, it will be very easy for managers and 
employees they favor to game the system by leaving the VA in order to 
return at a higher grade. VA managers already engage in far too much 
cronyism in both the hiring and pay processes.
    Section 11: This provision would establish a single database of 
vacant positions. AFGE generally supports this concept but is concerned 
that veterans working in VHA will be harmed by any increase in 
Secretary hiring discretion. More specifically, Congress should more 
closely monitor the VA hiring process to ensure that all applicants 
have a fair chance to be considered under this single database. 
Congress should also enact legislation to close the harmful loophole in 
the Veterans Employment Opportunities Act that deprives Title 38 
appointees of equal veterans' preference rights, allowing managers to 
pass them over for non-veterans in the hiring process. (Language to 
close this loophole was included in H.R. 2275 in the 113th Congress).
    Section 12: This provision would establish a VHA training academy 
to improve human resources (HR) training. AFGE supports improved 
training for HR personnel who appear to lack critical skills in areas 
such as coding personnel actions, applying shift differential pay rules 
and determining the cope of Title 38 bargaining rights. However, as we 
have seen from the VBA academy training program, on-the-job training 
under strong mentors is also a critical component of any training 
process.
    Section 13: This provision establishes a technical expert 
promotional track. AFGE supports.
    Section 14: This provisions mandates a GAO study of succession 
planning. AFGE supports with the provision that researchers adequately 
consider the input of front line employees and their representatives 
who have unique insights into training, recruitment and hiring.
    Section 15: This provision requires the Secretary to collect 
information on hiring effectiveness. AFGE generally supports more data 
collection but urges the Secretary to adequately consider the input of 
front line employees and their representatives who have unique insights 
into hiring. AFGE strongly opposes any increase in the use of special 
hiring authorities that adversely impact veterans' employment.
    Section 16: This provision would increase the use of excepted 
service appointments for students and recent graduates. AFGE strongly 
opposes this as it is likely to adversely impact veterans' employment.
    Section 17: This provision would improve and expand the 
Department's use of exit surveys. AFGE supports the use of exit surveys 
but will only support this provision if: (1) the Secretary adequately 
considers the input of front line employees and their representatives; 
and (2) the Secretary is required to share the survey results with 
employees and their representatives, veterans' groups and other 
stakeholders.

                                 
           NATIONAL ASSOCIATION OF VA PHYSICIANS AND DENTISTS
    Chairmen Benishek and Wenstrup, thank you for the opportunity to 
comment on your proposed legislation ``To improve the authority of the 
Secretary of Veterans Affairs to hire and retain physicians and other 
employees of the Department of Veterans Affairs and for other 
purposes.''
    I am a practicing physician with more than 4 decades with the VA 
and the President of the National Association of Veteran Administration 
Physicians and Dentists usually referred to as NAVAPD.
    I might add that I too am a veteran, having served for two years on 
active duty in the US Public Health Service.
    The National Association of VA Physicians and Dentists (NAVAPD) is 
a 501(c)(6) nonprofit organization and is dedicated to improving the 
quality of patient care in the VA health care system and ensuring the 
doctor-patient relationship is maintained and strengthened.
    NAVAPD believes that a key means of enhancing the care of the 
Veterans is by employing the best physicians and dentists. NAVAPD 
believes it is essential for health care providers to be involved in 
decisions regarding delivery and quality of care.
    In the late 1960s and 1970s nearly all of the VA Medical Centers 
were led by Directors who were physicians and your draft legislation 
says Veterans Affairs Medical Center and Veterans Integrated Service 
Networks directors ``may be appointed to suit the needs of the 
department, who, to the extent practicable, shall be a qualified doctor 
of medicine or a qualified dental surgeon or other qualified medical 
professional''. I strongly support this provision and suggest you 
consider eliminating ``who, to the extent practicable''.
    Currently, in the VA, the single greatest impediment to recruiting 
and retaining physicians and dentists is the disenfranchisement and 
marginalization that many of the current physicians and dentists 
experience daily. Today, most VA physicians and dentists feel like 
their opinions are neither helpful nor requested. In many facilities, 
their suggestions are summarily rebuffed as inconsequential. At many 
centers, physicians and dentists are no longer even considered 
professionals but referred to as simply the ``workers''. These 
observations do not just come from NAVAPD leadership, but directly from 
our members, VA docs and dentists. Men and women who want to help 
improve ``the system.''
    The proposed revisions to legislation regarding physician work 
hours would at least theoretically permit VA medical center leaders to 
unilaterally and dramatically alter a physician's tour indefinitely, 
and without any stated reason. Specifically, the provision which states 
``The Secretary may modify the hours of employment for employees in a 
position specified in any of paragraphs (1) through (6) of section 
7421(b) of this title to be more or less than 80 hours in a biweekly 
pay period if the total hours of employment for such an employee does 
not exceed 2,080 hours per calendar year.'' appears to make it possible 
for physicians to be told they must work every weekend, or move to 
night or evening shifts, or have frequently changing tours. While all 
physicians recognize that in a medical emergency they must do whatever 
they can to protect patients and treat immediate medical problems, any 
involuntary change in their negotiated tour should be motivated by a 
bona fide emergency that demands the attention of a physician. It 
stands to reason that these circumstances should have defined endpoints 
in time and clearly articulated goals, and should include a general 
staffing shortfall (where the services needed could be provided by non-
physicians). The authority proposed by this revision should be 
qualified by these stipulations.
    Recommend the legislation clarify the 24/7 rule's original intent 
that it go into effect only if a national or state emergency is 
declared by either a Governor or the President. Currently the 24/7 rule 
is used as a threat by hospital directors and it should not be used to 
intimidate the physicians and dentists. It also appears to be used as a 
no-cost method of solving staffing shortages or operational problems. 
This is an inappropriate abuse of privilege to solve the consequences 
of poor management.
    The following are - apart from the important matter of momentary 
compensation - key factors that are widely reported as undercutting 
physicians' performance and satisfaction.
    1. Denigration of CME. It is quite apparent that the VA has little 
regard for the continuing professional education of its physicians. 
Despite the fact that the Physician Pay Law of 2004 stipulates 
financial support of CME, it is regularly reported that the process for 
a physician to make use of the $1000 allocated for CME is so 
cumbersome, untimely and burdensome that many simply forego the 
education itself or in some cases pay out of pocket. Furthermore, the 
allocation is paltry in relation to actual, current CME costs. The 
Physician Pay Law uses the language ``up to $1000'' to indicate that 
the maximum funding is $1000 instead of the total cost of a much larger 
cost. Instead, hospital Directors have used this language to argue that 
they can provide any amount below $1000. This is the opposite intent of 
the law, and further frustrates physicians.
    One would think that the VA would see, as obvious, that the 
ultimate beneficiary of CME is the veteran-patient. Instead, the VA 
treats CME as an indulgence. The damage done is to the capability and 
morale of physicians as well as to patients. In, comparison with what 
the physician would have available in the private sector, it's hardly a 
recruiting tool; it is a disincentive to join or remain in the VA.
    2. Ignoring the Federal Physician Pay Law/Ghost pay. The VA often 
acts as if there is no legal foundation of physician pay. There is. 
Physician Pay has three legally defined components: Base Pay, Market 
Pay, and Performance Pay.
    In the Pay Law, performance pay is authorized up to $15,000 per 
physician and appropriated for incentivizing physicians, but no one 
seems to know where it goes, and some do not even seem to know that it 
exists. Local Directors arbitrarily restrict performance pay to any 
level they wish. How? Funds are allotted to VISNs and then to 
facilities for performance pay, but only smaller amounts are dispersed. 
Where are the remaining funds?
    Stipulated bi-annual market surveys and adjustments are skipped or 
ignored, market adjustments seem to go to ``favored'' staff members. 
Pay panels are assembled with pre-conceived performance pay outcomes. 
VA leaders at all levels (local, VISN, Central Office) need to be 
pressured to bring pay management into conformance with the Pay Law. 
The Pay Law is law, not a suggestion.
    Upper echelon VA management seems to think that continuing 
obscurity is the best way to handle this issue. In fact, however, what 
gets perpetuated is distrust and the sense that superiors are specially 
helping themselves and their friends with these funds. Transparency and 
behavior that is CONSISTENT with the Physician Pay Law are sorely 
needed.
    3. Disrespect Disparity. In a private sector organization, no one 
would expect a staff person to treat a physician as just another 
``worker'' nor expect that a physician would be without remedy when 
support personnel regularly fail to perform at a satisfactory levels. 
At VA facilities, a supporting employee - tech, secretary, etc. - sees 
his or her supervisor as the individual to be pleased, not the 
physician involved in patient care. Reports of this phenomenon are 
legion.
    This will not be remedied unless personnel come to see that 
properly supporting the physician is of paramount importance - and this 
will not occur unless there is a system whereby the physicians can 
anonymously rate personnel, including their supervisors. A department 
head should be held to explain why any such ratings within the 
department are low.
    Relatedly, there are many reports by physicians complaining that 
their time is taken up by basic secretarial work - a problem that would 
be much alleviated by making support staff concretely responsible to 
physicians rather than living in a parallel merit system controlled by 
a reigning supervisor. The VA has systematically shifted physician-
roles to non-physicians while simultaneously encumbering physicians 
with more non-physician duties, such as filing reports. This disrespect 
for physician skills and roles starts are the tops and filters down to 
all layers of the organization.
    4. The HR problem. HR has too wide a variety of responsibilities 
and some basic conflicts of interest - which cannot be remedied within 
HR.
    A key responsibility is to locate and intake needed personnel, 
particularly physicians. It is generally reported that the process is 
so slow and cumbersome that good recruits are routinely lost to other 
jobs. The draft bill proposes to offer education to HR personnel, but 
it does nothing to eliminate or streamline the requirements of the 
recruiting process that are the heart of the problem. The bill also 
needs to add accountability to the education. Lots of money is spent by 
the VA on educating HR personnel, but performance has not improved. 
This must change if VA is to turn its image around.
    Another key responsibility is to process and resolve employee 
(including physician) complaints about their working conditions or 
treatment by co-workers or superiors, but HR is hopelessly conflicted. 
HR works for management, not the employees. It naturally sees its 
function as one of employee pacification, not employee support and 
assistance. Given the numerous employee-biased programs within the 
government, HR fears retaliation for assertive corrective action and 
thus is reluctant to challenge problematic employees.
    Although the VA regularly issues declarations purporting to support 
employees' rights to challenge possible wrongdoing and inefficiencies, 
such declarations are toothless and largely ignored. There is a need to 
create a separate system - an ombudsman system, similar to the IG 
system where the ultimate authority lies outside the department - to 
process such employee grievances. There really is no other solution. 
Furthermore, this would free up HR to concentrate on other important 
functions, including recruiting.
    5. Shedding Stupid Rules. There are numerous physician complaints 
about time being misused by VA requirements for TMS testing - 
essentially unrelated to their duties of patient care. There are also 
rules that obstructively interfere with the flexible management of 
physician time. For example, if a physicians needs to make arrangement 
to be away for several hours in an afternoon to take care of a non-VA 
problem he or she must take off the entire day as personal time - a 
rule that serves little purpose but to irritate. If the VA has a 
serious interest in retaining physicians by creating a benign working, 
atmosphere, someone should be put in charge of weeding out noxious 
over-regulation.
    NAVAPD supports:

     modification to annual determination of staffing 
shortages;
     reemployment of former employees;
     recruiting database;
     Comptroller General study on succession planning VA-wide 
(although don't know why you don't ask GAO to do it now rather than 
wait for enactment)
     promotional opportunities for technical experts;
     information on hiring effectiveness; and
     exit surveys.

    While NAVAPD is largely focused on physician and dentist related 
issues, we cannot ignore issues that impact recruitment and retention 
of other critical professionals in the VA facilities. VA's ability to 
fully serve Veterans is also predicated upon sufficient levels of these 
personnel. Nursing is represented by its own unions and organizations, 
but other key professionals are not, and they are also critical to 
effective patient care. Many do not receive appropriate consideration 
of attractive pay and benefits to assure their recruitment and 
retention. We believe that arbitrary segmentation is counter to the 
need to attract and keep skilled staff. We believe that the Hybrid 
designation for many professionals (such as Respiratory Therapists) 
should be eliminated and these professions should be made full Title 38 
employees with the obligations and benefits of that designation.
    We applaud the intent of the Human Resources Academy but would 
recommend a review of the responsibilities of HR professionals and what 
could be consolidated/centralized so valuable time could be spent on 
recruitment/retention. The Department of Commerce is implementing a 
``shared service for HR processing department-wide'' and leaving 
policy, professional training, hiring decision-making at operational 
unit level. NASA has a similar operational model.
    Many of your provisions could be undertaken administratively by 
Veterans Affairs management if they had the political will. I am also 
including my recent statement before the Congressionally mandated 
Commission on Care in January.
    Thank you again for inviting NAVAPD to provide our comments 
regarding your important draft legislation.

                                 
            VETERANS AFFAIRS PHYSICAN ASSISTANT ASSOCIATION'
    Chairman Benishek, Chairman Wenstrup, Ranking members; 
Congresswoman Brownley, Congressman Takano and other members of the 
House Veterans Affairs Subcommittees on Health and Economic 
Opportunity, on behalf of the entire membership of the Veterans Affairs 
Physician Assistant Association (VAPAA) we appreciate the invitation to 
submit this testimony for the record. We thank bipartisan members of 
this committee for critical legislation for Physician Assistant (PA) 
Workforce issues before you today in the VA System with sponsoring 
`Grow Our Own Directive: Physician Assistant Employment and Education 
Act of 2015.'' (S.2134) and (H.R. 3974) and we thank Congresswoman Ann 
Kuster for her leadership on this bill.
    The Physician Assistant (PA) profession has a special unique 
relationship with veterans. The very first classes of physician 
assistants to graduate from PA educational programs were all former 
Navy corpsmen and Army medics who served in the Vietnam War and wanted 
to apply their knowledge and experience in a civilian role in 1967. 
Today, there are 199 accredited PA educational university programs 
across the United States and approximately 2,020 PAs are employed by 
the Department of Veterans Affairs (VA), making the VA the largest 
single federal employer of PAs. These PAs provide high quality, cost 
effective quality health care working in hundreds of VA medical centers 
and outpatient clinics, providing medical care to thousands of veterans 
each year in their clinics. Physician Assistants work in both 
ambulatory care clinics, emergency medicine, CBOC's in rural health, 
and in a wide variety of other medical and surgical subspecialties. 
1A\1\ 1A\2\ In the VA system about a quarter of all primary care 
patients treated are seen by a PA 1A\3\. Approximately 32% of PAs today 
employed by VHA are veterans, retired military, or currently serving in 
the National Guard and Reserves.
---------------------------------------------------------------------------
    \1\ 1AWilliam Fenn, PhD, PA, Vice President, American Academy of 
Physician Assistants, Testimony before the United States Senate 
Committee on Veterans Affairs, Hearing on S. 1155, a bill to elevate 
the VA's PA Advisor to a full-time director of PA services in VA 
central office, (October 21, 2009)
    \2\ 1APhysician Assistant Education Association, Letter to Senate 
Majority Leader Harry Reid and Speaker of the House Nancy Pelosi 
(January 15, 2010) http://www.paeaonline.org/index.php?ht=a/
GetDocumentAction/i/99520
    \3\ 1AAmerican Academy of Physician Assistants, Press Release 
(March 5, 2011) http://www.aapa.org/news--and--publications/pa--pro--
now/item.aspx?id=1917
---------------------------------------------------------------------------
    The Veterans Affairs Physician Assistant Association (VAPAA) 
maintains that Physician Assistants are a critical component of 
improving VA health-care delivery, and have consistently recommended 
that VHA include them in all health-care national strategy staffing 
policy plans. Since our testimony last May, the VA has identified that 
both in VA OIG Reports, and VHA Succession Planning Committee that the 
PA occupation is in top five critical healthcare occupations with high 
retention and vacancy problems. However, since January 1993 when VA 
added the Title 38 GS 0913, Chief Grade more than 22 years ago, little 
else has been done for this critical workforce and hope that as these 
committees review changes to improve access to care for veterans and 
oversight on VHA strategy for its healthcare workforce that changes 
will be included to address these PA problems.
    Civilian Growth Physician Assistant Profession
    Forbes, US News & World Report, and New York Times articles all 
again named Physician Assistant occupation the single best master's 
degree for the third year in a row, citing the profession's favorable 
outlook for salary and long-term employment. The PA field was listed as 
one of the 50 best careers in 2014 due to increasing demand for health-
care services, the impending retirement of baby boomers, and broader 
efforts to limit health-care costs. 1A\2\According to the US Bureau of 
Labor Statistics the PA profession is expected to grow by 30% from 2012 
-2022
---------------------------------------------------------------------------
    \2\ 1A[2] US News and World Report, Best Careers 2011: Physician 
Assistant (December 6, 2010) http://money.usnews.com/money/careers/
articles/2010/12/06/best-careers-2011-physician-assistant
---------------------------------------------------------------------------
    In early February, VA Secretary Bob McDonald and USH Dr. Shulkin 
testified about the challenges facing VHA in hiring employees. 
Secretary McDonald told the House Veterans Affairs Committee that he 
has personally visited dozens of colleges to recruit medical students, 
but that the people he talked to had the perception that the agency was 
intent on firing its employees. The VA also struggles to recruit 
medical personnel away from the private sector to come to the agency 
where they are likely to have a lower salary and be posted to less 
desirable, rural locations.
    The VA hired 41,000 new employees last year, but that represented a 
net increase of only about 14,000 staff, or 4.7 percent of the Veterans 
Health Administration payroll, according to Secretary McDonald's 
prepared statement for the House VA Committee. The department said in 
an emailed statement early February that the VA has about a 9 percent 
turnover rate - which it said is better than an 18 percent turnover 
rate in the private sector.
    VA officials said the current staffing shortage mirrors national 
trends in health care, where a study by the Association of American 
Medical Colleges predicted that the shortage of physicians could range 
from 46,000 to 90,000 in the next 10 years. 1A\4\
---------------------------------------------------------------------------
    \4\ 1ASecretary VA Budget Testimony February 2016 before House VA 
Committee on VA Budget
---------------------------------------------------------------------------
    VHA Recruitment and Retention of Physician Assistants; Problems 
Continue to rise
    Physician Assistants provide health care access for millions of 
veterans each year, VHA has not developed any strategic national plans 
to address the chronic 10% to 14% total loss rate, which is one of the 
highest of any profession in VHA - top five hard to recruit 
occupations. With the existing reported disparity in pay between PAs 
employed by the VA and the private sector market this problem continues 
to grow. For several years, The Independent Budget veterans service 
organizations (IBVSOs) along with American Academy Physician Assistants 
(AAPA), and Veterans Affairs Physician Assistant Association (VAPAA), 
have all recommended that Congress ensure the retention and recruitment 
problems for PA's be immediately rectified with new national targeted 
policy and programs for this critical occupation.
    The VA Office of Inspector General (OIG) Report #15 0900430 09103, 
January 30, 2015; conducted a determination of Veterans Health 
Administration (VHA) occupations with the largest staffing shortages as 
required by Section 301 of the Veterans Access, Choice, and 
Accountability Act of 2014. VAOIG determined Physician Assistant, were 
3rd compared to all other VHA occupations with the largest staffing 
shortages. 1A\5\ In addition to the VAOIG report the National Workforce 
Succession Planning 2015 - the data demonstrates the scope of the 
problems.
---------------------------------------------------------------------------
    \5\ 1AVAOIG Report #15 0900430 09103, January 30, 2015 VA Health 
Care Critical Occupations Staffing
---------------------------------------------------------------------------
    Data VHA National Workforce Succession Planning 2015

     In 2016 37% of VHA PA is eligible to retire. That is 
approximate loss of 600 Physician Assistants. By 2021 48% of VHA PA's 
are eligible to retire.
     2014 - PA's had the highest Total Loss Rate of 10%; of the 
other top ten occupations.
     2014 - 14.28 % VHA PAs left the VA due to Compensation 
(salary and benefits).

    The PA workforce has grown far less than other physician extend 
positions within the VHA and little is being done about it; therefore, 
what should be a warning signal of serious retention and recruiting 
problems is being left to local VAMCs to manage. Despite increasing 
discrepancy in salary levels, benefits, and education debt reduction 
programs between the civilian sector and the VAMCs often tells our 
members there is no problem. Currently Physician Assistants remain in 
an antiquated pay system with no competitive market survey resulting in 
a large pay disparity with the civilian sector. Last May I testified 
that the VA utilize the Nurse Locality Pay System surveys (LPS) 
allowing for annual market salary surveys aligning these professions 
within the VA with the private sector market. Inclusion of Physician 
Assistants into the Nurse LPS within Grow Our Own Directive H.R. 3974 
will allow for salary adjustments so that the VHA can be competitive.
    VAPAA is also concerned that the use of recruitment incentives 
within the VA is at the discretion of the hiring facility and is not 
standardized across the VA system. During 2012 092013 only 44 Physician 
Assistants have received $319,074 in funding to further their education 
in comparison to Seven hundred five registered nurses seeking to become 
Nurse Practitioners receiving scholarship awards totaling over 
$11,842,919 in support of NPs and NP programs. VA should implement 
recruitment and retention tools targeting Employee Incentive 
Scholarship Program by including PA as a hard to recruit occupation at 
the facility level to reflect WSP and OIG findings. Include Employee 
Debt Reduction Program funding to include PAs and make it available to 
all advertised PA vacancy announcements as EDRP cannot be issued unless 
it is advertised in the initial vacancy announcement. VISN and VA 
medical center directors must be held accountable for the failure to 
utilize these recruiting tools. Evidence of the problem from small 
sample of VAMC's reflecting lack of VHA controls on providing 
scholarships to PAs.
    New Orleans Office the National Healthcare Recruiter, Workforce 
Management & Consulting VHA Healthcare Recruitment & Marketing said 
they have no Health Professional Scholarship Program (HPSP) funds of 
their own, so they are using funds provided by the VACO Office of 
Academic Affiliations to provide HPSP to nurses who want to be NPs. 
They have stated that these funds are not available to Intermediate 
Care Technician (ICTs) combat OIF OEF veterans, seeking to become PAs. 
The same office assured senior PA office representatives at the same 
time that they have EISP VANEEP/NEEI scholarship funds are available 
for VAMCs who request the funds.
    Cincinnati VAMC has told their ICTs who asked for VANEEP for PA 
education that they have been ``out of'' VANEEP funds for the last 4 
years. What exactly does that mean since the funds come from New 
Orleans? No VAMC funds the VANEEP locally.
    San Diego VAMC told one of our ICT that they have ``suspended'' all 
scholarships and no support for PA students will occur.
    The VAMC in Spokane told an ICT that PAs were not a critical 
occupation in the VA and that therefore she was not eligible for VA 
scholarship funds.
    PAs then across the country find on USA JOBS web site and in VA 
news stories the following: Through its network of academic 
affiliations and sponsored programs, VA invests $900 million annually 
to provide clinical education and training programs to approximately 
120,000 health care trainees. Sixty percent of VA's psychiatrists, 70 
percent of its psychologists and 35 percent of its social workers have 
previously participated in VA's training programs.
    These committees must make certain that opportunities for required 
PA continuing medical education and training exist within the VA 
education programs. Physician Assistants provide high quality, cost 
effective medical care as they are held to the same standards of health 
care delivery as their MD/DO VA colleagues who are afforded a yearly 
stipend for continuing educations. PAs must maintain CME hours. 
Physician Assistants mush recertify by examination every 10 years. In 
order to be competitive with the civilian sector, the VA must make 
certain that employees gain opportunities for required PA professional 
development and continuing education and training in support in 
maintaining a high level of professional competence.
    Continued Delays in Hiring PA Employees
    VAPAA has found since last May's hearing that whenever a PA 
employee leaves the VA system, VA acknowledges that it can take still 
six months to a year to fill one vacant position-assuming a viable pool 
of candidates is interested and available. When VA seeks to replace 
health care professionals, VA cannot compete with nimble private health 
care systems. The lengthy process VA requires for candidates to receive 
employment commitments and boarding continues to hinder the VA ability 
to recruit and officially appoint new employees.
    Private health care systems can easily fill PA vacancies in a 
matter of days or weeks. While PA applicants may have noble intentions 
of working for the VA and serving veterans, many will forgo what could 
be a 4 to 6 month long waiting period and pursue timely employment 
opportunities elsewhere. For these reasons, we ask Congress to 
carefully review VA appointment authorities, internal credentialing 
processes, and common human-resources practices to identify ways to 
streamline the hiring process. If VA takes months to fill its health 
care vacancies, VA will continue to fail the delivery of timely, 
quality care to our nation's veterans.
    Members of HVAC and SVAC both introduced bipartisan legislation 
last October, providing for specific plans for Grow Our Own, asking 
that VA utilizing VHA provisions (Titles III and VIII of the newly 
enacted Veterans Access, Choice, and Accountability Act of 2014) to 
include the national VHA plans for expanding recruiting for new FTEE PA 
positions and for retaining an optimal PA workforce utilizing our 
recommendations below.
    Department of Veterans Affairs ``Independent Care Technician'' 
(ICT) Program, One Solution to Support Transitioning Medics and 
Corpsmen OIF OEF OND into ``Grow Our Own'' to Physician Assistant 
Occupation
    VAPAA points to another solution for meeting the healthcare 
workforce challenges in a recent pilot program. On October 26, 2011, 
the Administration announced its commitment to providing support to 
unemployed Post 9/11 combat veterans and it highlighted the PA 
profession as a prominent targeted career path for new returning 
veterans who had served as medics and corpsmen with combat medical 
skills similar to the history of returning Vietnam War veterans with 
these skills within the ICT pilot VA program at 19 VA sites. Under this 
initiative, the Administration promoted incentives to create training, 
education, and certifications of these veterans needing in transition 
to a civilian application of their military medical skills, being hired 
to work inside VA emergency departments, and has expanded into primary 
care, mental health, and surgery clinic positions. While these ICT 
veterans should be provided VANEEP, EDRP, EISP, and HPSP scholarships 
for entering accredited PA University programs they are being told by 
local facilities they have no funds for them, only for Nursing 
Educational programs.
    The VA has an excellent opportunity to facilitate and coordinate 
``Grow Our Own'' combat medics, Corpsmen, or Air Force paramedics to 
transition to the physician assistant occupation. However the (ICT's) 
currently in the Grow Our Own VA program are being frustrated by 
statements they should not expect scholarships from VA, and there is 
lack of VHA policy language directing VAMCs to ensure educational 
support of these combat veteran PA program candidates, assisting them 
in admission to accredited PA university Master's programs with 
targeted scholarships for PA Education. Ten former OIF OEF combat 
veterans already enrolled in University PA program in Tennessee are 
told they will not be eligible for scholarships.
    The VAPAA is concerned over this ICT program started in 2012, 
reported to be expanding to more full time ICTs. The continued lack of 
use of recruitment educational incentives within VHA and having it left 
at the discretion of the local hiring facility is setting up further 
frustration across the VA system with the lack of VHA scholarships for 
the critical PA occupation. The Office of VA Healthcare Retention and 
Recruitment and the VAMC's participating in the pilot ICT program have 
no dedicated VHAS support to transition them into PAs in the Employee 
Incentive Scholarship Program (EISP) or EDRP. The barriers to PA 
recruitment and retention will continue unless congressional members 
provide oversight, VHA must ensure that employee incentive programs, 
such as the EISP and the VA Employee Debt Reduction Program are made 
consistently available to all critical healthcare workforce PA vacancy 
announcements and utilized in ICT the program. VISN and VA medical 
center directors they must be held accountable for the failure to 
utilize these recruiting tools.
    The ICT Program establishment and expansion was authorized by the 
SEC VA in March 2015. The program expansion will increase ICTs in the 
VA from the original 45 by hiring 234 more ICTs. Hiring the additional 
234 ICTs has been left to the discretion of the Facility Directors of 
individual VAMCs.
    Between March 2015 when the ICT expansion was approved and March 
2016, less than 6 of the additional 234 ICTs have actually been hired 
by the VA. VHA was supposed to develop a national VA veteran employment 
program targeting OIF OEF combat medics and corpsmen that is being 
managed by local VAMCs with little oversight from VHA or VISN 
Directors.
    Critical Workforce Occupations:
    VA's mission statement for human resources is to recruit, develop, 
and retain a competent, committed, and diverse workforce that provides 
high quality service to veterans and their families. VA identifies 
specific occupations as ``critical occupations'' based on the degree of 
need and the difficulty in recruitment and retention. There are 3 types 
of primary care clinical providers within the VA that provide direct 
patient care - Physicians, Physician Assistants and Nurse 
Practitioners. Physicians have mandated yearly market pay survey. Nurse 
Practitioners, by virtue of being a nurse, are under the mandated 
yearly RN LPS.
    PAs in few facilities fall under Special Salary Rates; however, 
this is NOT mandated yearly. Some facilities have not performed a 
special salary survey for 11 years, resulting in the reporting in the 
VISN 2014 0915 Workforce Succession Plan - 12 out of the 21 VISNs (88 
VA main facilities) reported the reason that their VISN cannot hire 
PA's is because they cannot compete with the private sector pay. Some 
VAMCs have refused to pursue steps to solve the current retention 
problems for PAs.
    Recommendations: We ask that both committees recognize the 
advantages to the Recruitment and Retention of Physician Assistant (PA) 
Workforce in the VA System by supporting enactment and supported by the 
veteran service organizations at the November 18, 2015 hearing on S. 
2134 and call attention the VHA witness Dr. Carolyn McCarthy testified 
in favor of this legislation `Grow Our Own Directive: Physician 
Assistant Employment and Education Act of 2015.'' (S.2134) and (H.R. 
3974)
    HR 3230 - Veterans Access, Choice, and Accountability Act of 2014 
directs the Secretary, under the VA's Health Professionals Education 
Assistance program, to give scholarship priority to applicants pursing 
education or training towards a career in a health care occupation that 
represents one of the five largest staffing shortages.
    The measure used under the Choice Act- OIG Top 5, prevents PA 
eligibility for EISP scholarship funds, as EISP - VANEEP, NEEI (VHA 
handbook 1020) conveniently only recognizes local facility workforce 
succession planning and ignores the OIG top five.
    To prevent local nursing bias, include PA at all facility level to 
reflect WSP and OIG findings as a hard to recruit occupation as this is 
the qualifying factor for EISP funding - VANEEP/NEEI
    In VHA Handbook 1020 - Employee Incentive Scholarship Program 
(EISP) Procedures: includes a priority protocol for nursing only 
scholarship funds, (1) applicants enrolled in academic programs which 
provide the minimum education for entry level in to the occupation RN 
to BSN, (2) RN to Master's degree program (NP), (3) RN to doctorate 
(NP), and (4) RN to a degree related to their occupation.
    Include PAs in the hierarchy for funding allocations for EISP - 
VANEEP, NEEI scholarship funds. Include medicine - Designated Learning 
Officer (DLO) a part of the local facility selection committee for 
applicants.
    Include EDRP in all PA job postings.
    Include targeted scholarships for the ICT program OIF OEF Grow Our 
Own returning veterans, and mandate VHA shall appoint PA ICT program 
director to coordinate the educational assistance necessary and be 
liaison with PA university programs.
    H.R. 3974 would direct new Physician Assistant director position to 
work within the National Healthcare Recruiter, Workforce Management & 
Consulting VHA Healthcare Recruitment & Marketing Office. This position 
then can develop targeted recruiting plans with 187 PA programs, 
working in a way that the local Human Resource Officer (HRO) often will 
not due to lack of staffing. The VA employed PA national Healthcare 
Recruiter would develop improvements in finding qualified candidate in 
a matter of days not months. VHA must incorporate new PA consultant 
manager into this National Healthcare Workforce program office.
    Conclusion:
    Chairman Benishek and Chairman Wenstrup, and Ranking member 
Brownley and Takano, other members of HVAC committee as you strive to 
ensure that all veterans receive timely access to quality healthcare 
and as you build increased capacity for delivery of accessible high 
quality health care, and demand more accountability into the VA health 
care system, I strongly urge the full Committee to review the important 
critical role of the PA profession and ensure legislatively that VHA 
takes immediate steps to address these longstanding problems and 
continue to work with VAPAA in supporting our nation's veterans.
    DISCLOSURE OF FEDERAL GRANTS OR CONTRACTS
    Veterans Affairs Physician Assistant Association
    The Veterans Affairs Physician Assistant Association (VAPAA) does 
not currently receive any money from a federal contract or grants. 
During the past six years, VAPAA has not entered into any federal 
contracts or grants for any federal services or governmental programs.
    VAPAA is a 501c (3) nonprofit membership organization.

                                 
                NURSES ORGANIZATION OF VETERANS AFFAIRS
          STATEMENT OF SHARON JOHNSON, MSN, RN 09BC, PRESIDENT
    Chairman Benishek, Chairman Wenstrup, and Members of the 
Subcommittees on Health and Economic Opportunity, on behalf of the 
nearly 3,000 members of the Nurses Organization of Veterans Affairs 
(NOVA), I would like to thank you for the opportunity to submit 
testimony on today's draft legislation to Improve the Authority of the 
Secretary of VA to Hire and Retain Physicians and other Employees of 
the Department of Veterans Affairs.
    NOVA is a professional non-profit organization for registered 
nurses employed by the VA.
    NOVA appreciates the opportunity to provide our input and, as 
nurses who make up one third of the VA workforce, we will highlight 
areas of concern that are pertinent to our mission.
    While overall we appreciate the intent of the bill and support any 
activities that will improve how VHA hires, retains and recruits its 
workforce, the bill as written, does very little to affect nursing 
personnel and the staffing shortages being felt nationwide.
    For example, Section 2, paragraph 4 states that the Medical 
Director should be a doctor or other qualifying medical professional. 
NOVA believes that this minimizes the expertise of those professionals 
who are trained in healthcare and administration and limits flexibility 
in hiring within these leadership positions.
    Section 2 (7) (D) for clarification, mention is made of ``Advanced 
Degree in Mental Health'' and line 18 has Nursing Assistant. Nursing 
Assistants have no degrees and perhaps this was inserted in error.
    Section 3 - Adjustment of Hours Authorized for Certain Full-Time 
Employees of VHA implies that any hours can be worked to meet the 
biweekly pay period of 80 hours with a cap at 2,080 in a calendar year. 
NOVA has concerns that payroll and human resources systems will not be 
able to manage this change unless IT software is rebooted and HR staff 
is trained to meet this change.
    NOVA applauds Section 5, which would clarify staffing shortages and 
include clinical as well as non-clinical personnel as needed.

NOVA has no comments on Sections 6 through 9 of the Draft Bill.

    Section 10 - Reemployment of Former Employees.
    While NOVA appreciates the need to recapture former employees to 
help with staffing shortages within VA, for RN appointments, the grade 
is based on the Nurse Qualification Standards so the employed 
candidates would need to meet those standards. The scope is different 
for each grade. A reemployed candidate may not meet the qualifications 
for the next higher grade. And while it may be competitive, it could 
also be inequitable for those already employed using qualification 
standards under the accepted service position.
    Section 11- Recruiting Database.
    It is unclear to us how a national data base will work and what the 
expectation is. Problems often arise with national databases unless 
there is a short time period that applicants remain ``active (i.e. 30 
or 60 days) within the system and effective management of the database 
is provided. Good candidates would be scooped up quickly or will get 
other offers outside VA. For positions identified as mission critical, 
there should be greater pay flexibility built in to be competitive and 
attract candidates to those positions. For example, if an engineer or 
HR Specialist is a mission critical occupation and there are no hiring 
flexibilities, it will not help if they leave to go to other agencies 
or the private sector for more pay or higher grades.
    Section 12 - Hiring Academy.
    Retention of HR Specialists is of concern to NOVA. While an HR 
Academy is a noble idea, unless the workload and ineffective systems 
under HR are addressed, a high vacancy rate and ongoing retention 
issues will continue to be a concern. We also add that there should be 
something more specific that defines the appropriate training milieu 
based on the complexity of HR, such as face to face training when 
needed, and ensuring funds for travel are appropriated to continue 
providing effective training for all HR staff.
    Section 13 - Promotional Opportunities for Technical Experts.
    NOVA applauds this section and recognizes that technical experts 
need to be able to obtain promotions without having to leave their 
roles and pursue a managerial position.
    Section 14 - Comptroller General Study on Succession Planning. NOVA 
has no issues with this section.
    Section 15 - Information on Hiring Effectiveness.
    We appreciate a system to track use and impact of hiring 
authorities and flexibilities. NOVA has already testified that there is 
a knowledge gap in hiring authorities and flexibilities within HR. We 
also applaud the inclusion of a process for tracking satisfaction and 
timeliness of the hiring process.
    Section 16 - Employment of Students and recent Graduates.
    NOVA supports the allowance of excepted service appointments and 
recent graduates. NOVA is an advocate of staff developmental 
opportunities such as internships and residency programs.
    Finally, Section 17 looks to standardize the process for exit 
interview surveys, which is critical in measuring and identifying any 
common themes so that action could be taken as well as assisting in 
identifying opportunities for improving the workforce environment 
within VA.
    In summary, NOVA supports all efforts directed towards the 
retention, as well as recruitment for the VHA's largest workforce. 
Reviewing and enhancing nurse pay to be competitive with community and 
private sector standards; removing the cap from nurse pay scales to 
enable current employees to apply for critical leadership positions and 
increased support with monies for travel and education for nursing 
staff would go a long way in enhancing the VA as the employer of choice 
for healthcare professionals across the nation.
    Staffing methodology should be the accepted and supported mechanism 
for all facilities that VACO supports to determine nurse staffing, as 
well as having the Chief Nursing Officer at the table when patient care 
decisions and planning is made.
    Once again, NOVA thanks the Committees for the opportunity to 
submit testimony and we would be happy to assist with adding language 
in the bill to accommodate and revise any of the issues mentioned in 
our testimony.

    Statement on Receipt of Grants or Contract Funds: Neither Ms. 
Sharon Johnson, nor the organization she represents, the Nurses 
Organization of Veterans Affairs (NOVA), has received federal grant or 
contract funds relevant to the subject matter of this testimony during 
the current or past two fiscal years.

                                 
                            MERRITT HAWKINS
                TRAVIS SINGLETON, SENIOR VICE PRESIDENT
Overview:

    We would first like to thank Dan Benishek, M.D., Chairman of the 
Committee of Veterans' Affairs Subcommittee on Health, and Brad 
Wenstrup, Chairman, Subcommittee on Economic Opportunity, for the 
opportunity to submit this statement of record concerning draft 
legislation to improve the ability of VA healthcare facilities to 
effectively recruit and retain qualified physicians and other 
employees.
    Merritt Hawkins is the largest physician search and consulting firm 
in the United States, carrying out over 3,100 physician and advanced 
practitioner search assignments annually for healthcare facilities 
located in all 50 states. Established in 1987, Merritt Hawkins is a 
company of AMN Healthcare (NYSE: AHS), the largest healthcare staffing 
organization in the country and the innovator of healthcare workforce 
solutions.
    Over the course of 27 years of providing physician search services 
to the healthcare industry, Merritt Hawkins has worked with VA 
healthcare facilities in all regions of the country. Most recently, we 
have partnered with VA facilities on physician or advanced practitioner 
search assignments at VISN 20, VISN 4, VISN 16, VISN 23, VISN 1, and 
VISN 20. We are currently the only permanent placement physician search 
firm that has a GSA number and is listed on 738X.
    In addition, we have worked with hundreds of other government 
sponsored or supported healthcare facilities where the physician 
recruiting dynamics are similar to those typically present at VA 
facilities. These include numerous Federally Qualified Health Centers 
(FQHCs), Indian Health Service (IHS) facilities, and Department of 
Defense facilities.
    In December, 2015, Merritt Hawkins submitted a Statement of Record 
for a roundtable discussion regarding how to improve the ability of the 
Department of Veteran's Affairs to efficiently and effectively recruit 
and retain high quality physicians and other employees. Based on our 
knowledge of physician staffing and physician practice patterns, 
Merritt Hawkins' president, Mark Smith, was invited in July, 2012, to 
provide testimony before the House Committee on Small Business on the 
decline of solo and small physician practices.
    In addition to our work with VA and other government sponsored 
facilities, Merritt Hawkins has worked with thousands of private sector 
healthcare systems, community hospitals, academic centers, medical 
groups, urgent care centers, retail clinics, and other facilities. We 
therefore have an extensive background from which to draw in comparing 
the best physician recruiting practices of government facilities, such 
as the VA, to those of a wide range of other facilities in the private 
sector.
    We will make such comparisons further in this statement but will 
first briefly address prevailing conditions in today's physician 
recruiting market.

Medical Professional Recruitment: Market Context

    In the previous Statement of Record Merritt Hawkins submitted to 
the Subcommittees in December, 2015 we outlined prevailing physician 
recruiting market conditions in today's rapidly evolving healthcare 
system. We will not repeat this entire discussion here, but will state 
that both the government and the private healthcare sectors are 
challenged by prevailing physician shortages which are projected to 
worsen.
    The Association of American Medical Colleges (AAMC) projects a 
shortage of up to 91,000 physicians by 2025 (see The Complexities of 
Physician Supply and Demand, Association of American Medical Colleges, 
March 2015). The shortage is being driven by a growing and aging 
population, advances in medical technology, and the increased 
availability of health insurance through the Affordable Care Act. 
Fueling the shortage is the fact that residency training positions for 
medical graduates have grown only incrementally over the last 18 years, 
as federal funding for physician training was capped by Congress in 
1997.
    The effect of these shortages is apparent in Merritt Hawkins' 2014 
Survey of Physician Appointment Wait Times and Medicaid and Medicare 
Acceptance Rates. The survey examines the time needed to schedule a new 
patient appointment in five medical specialties in 15 major metro 
markets
    The chart below shows average wait times to schedule a new patient 
appointment with a family physician in the 15 metro markets examined in 
the survey:

                          Wait Time in Days to Schedule a New Patient Appointment With a Family Physicians in 15 Metro Markets
--------------------------------------------------------------------------------------------------------------------------------------------------------
                            City                              Shortest Time to Appointment   Longest Time to Appointment    Average Time to Appointment
--------------------------------------------------------------------------------------------------------------------------------------------------------
Boston, 2014                                                                      12 days                       152 days                        66 days
--------------------------------------------------------------------------------------------------------------------------------------------------------
Boston, 2009                                                                       6 days                       365 days                        63 days
--------------------------------------------------------------------------------------------------------------------------------------------------------
New York, 2014                                                                    14 days                        38 days                        26 days
--------------------------------------------------------------------------------------------------------------------------------------------------------
New York, 2009                                                                     6 days                        61 days                        24 days
--------------------------------------------------------------------------------------------------------------------------------------------------------
Atlanta, 2014                                                                       1 day                       112 days                        24 days
--------------------------------------------------------------------------------------------------------------------------------------------------------
Atlanta, 2009                                                                      3 days                        21 days                         9 days
--------------------------------------------------------------------------------------------------------------------------------------------------------
Seattle, 2014                                                                      3 days                       129 days                        23 days
--------------------------------------------------------------------------------------------------------------------------------------------------------
Seattle, 2009                                                                      2 days                        14 days                         8 days
--------------------------------------------------------------------------------------------------------------------------------------------------------
Philadelphia, 2014                                                                  1 day                        98 days                        21 days
--------------------------------------------------------------------------------------------------------------------------------------------------------
Philadelphia, 2009                                                                 3 days                        15 days                         9 days
--------------------------------------------------------------------------------------------------------------------------------------------------------
Los Angeles, 2014                                                                   1 day                       126 days                        20 days
--------------------------------------------------------------------------------------------------------------------------------------------------------
Los Angeles, 2009                                                                   1 day                       365 days                        59 days
--------------------------------------------------------------------------------------------------------------------------------------------------------
Houston, 2014                                                                       1 day                       178 days                        19 days
--------------------------------------------------------------------------------------------------------------------------------------------------------
Houston, 2009                                                                       1 day                        29 days                        17 days
--------------------------------------------------------------------------------------------------------------------------------------------------------
Denver, 2014                                                                        1 day                        62 days                        16 days
--------------------------------------------------------------------------------------------------------------------------------------------------------
Denver, 2009                                                                        1 day                        45 days                        14 days
--------------------------------------------------------------------------------------------------------------------------------------------------------
Detroit, 2014                                                                       1 day                        74 days                        16 days
--------------------------------------------------------------------------------------------------------------------------------------------------------
Detroit, 2009                                                                      3 days                        31 days                        14 days
--------------------------------------------------------------------------------------------------------------------------------------------------------
Wash., D.C., 2014                                                                   1 day                        62 days                        14 days
--------------------------------------------------------------------------------------------------------------------------------------------------------
Wash., D.C., 2009                                                                  3 days                       365 days                        30 days
--------------------------------------------------------------------------------------------------------------------------------------------------------
Portland, 2014                                                                     3 days                        45 days                        13 days
--------------------------------------------------------------------------------------------------------------------------------------------------------
Portland, 2009                                                                     3 days                        16 days                         8 days
--------------------------------------------------------------------------------------------------------------------------------------------------------
Miami, 2014                                                                         1 day                        56 days                        12 days
--------------------------------------------------------------------------------------------------------------------------------------------------------
Miami, 2009                                                                         1 day                        25 days                         7 days
--------------------------------------------------------------------------------------------------------------------------------------------------------
Minneapolis, 2014                                                                   1 day                        30 days                        10 days
--------------------------------------------------------------------------------------------------------------------------------------------------------
Minneapolis, 2009                                                                  2 days                        23 days                        10 days
--------------------------------------------------------------------------------------------------------------------------------------------------------
San Diego, 2014                                                                     1 day                        17 days                         7 days
--------------------------------------------------------------------------------------------------------------------------------------------------------
San Diego, 2009                                                                     1 day                        92 days                        24 days
--------------------------------------------------------------------------------------------------------------------------------------------------------
Dallas, 2014                                                                        1 day                        10 days                         5 days
--------------------------------------------------------------------------------------------------------------------------------------------------------
Dallas, 2009                                                                        1 day                        27 days                         8 days
--------------------------------------------------------------------------------------------------------------------------------------------------------
Total, 2014                                                                     2.87 days                      79.3 days                      19.5 days
--------------------------------------------------------------------------------------------------------------------------------------------------------
Total, 2009                                                                     2.47 days                      99.6 days                      20.3 days
--------------------------------------------------------------------------------------------------------------------------------------------------------

    As these numbers indicate, average family physician appointment 
wait times exceed 14 days in ten of the markets, and equal or exceed 21 
days in five of the markets. In other markets with fewer physicians per 
capita, it is likely that wait times may be more protracted. It is 
therefore not just VA patients who are experiencing protracted 
physician appointment wait times.
    Today, a proliferating number of sites of service are competing for 
a limited pool of physicians, PAs and NPs, as healthcare delivery 
transitions from a hospital based model to an outpatient and 
``convenient care'' based model. Thousands of urgent care centers, 
ambulatory surgery centers, retail clinics, FQHCs, free-standing 
emergency rooms, major employers, and insurance companies are actively 
recruiting physicians, along with more traditional types of employers, 
including hospitals, hospital systems, academic medical centers, and 
government facilities such as the VA.
    The type of physicians that VA facilities historically have been 
able to recruit, including active military and former military 
physicians, are increasingly being contacted and recruited by a wide 
range of private sector facilities.
    Due to this competitive climate, it is important for healthcare 
facilities to have a strategic recruiting plan, to accurately forecast 
their needs, to be nimble and responsive, to offer competitive 
incentives, an attractive work environment, and, of most importance, to 
bring a consistent sense of urgency to the recruiting process.

VA Facility Recruiting Methods and Challenges

    In Merritt Hawkins' 2015 Statement of Record referenced above we 
outlined various physician recruiting challenges faced by VA 
facilities.
    To recap, the first and most challenging is the recruiting process 
itself, as administrated by the various VA facility human resource 
departments. A sense of urgency and the ability to be agile is critical 
in today's physician recruiting market.
    Physician candidates being sourced by the VA typically also are 
receiving job offers from many other organizations. The great majority 
of VA facilities with which we work are handicapped by the prolonged 
time needed to process candidates who have been selected for VA 
employment through security and other bureaucratic requirements. 
Processing times at VA facilities to receive clearance on hiring 
candidates often can run as long as six months. By contrast, 
efficiently run private hospitals typically turnaround the same level 
of paperwork in no longer than four weeks. In the private sector, this 
process often occurs concurrently with the recruiting process.
    These waiting times do not include the process required to approve 
candidate interviews before a job offer is made. The process to approve 
candidate interviews may be channeled through four or five individuals 
who have a variety of duties and may not appreciate the urgency of 
approving physician interviews quickly. In Merritt Hawkins' experience, 
it may take up to three months to schedule two to three interviews for 
the same position. It also may be difficult for candidates to submit 
required information, and their applications may be rejected for 
lacking certain basic information without the candidate's knowledge. 
They simply do not hear back and assume they did not get the job.
    In recent physician recruitment efforts in Alaska that Merritt 
Hawkins conducted on behalf of the VA, we were successful in placing 10 
physicians in the Wasilla, Anchorage and Fairbanks areas. All ten 
physicians accepted offers with the VA but the contract approval 
process was so protracted and laborious that nine of the ten physicians 
withdrew from consideration.
    A key part of the problem in Merritt Hawkins' experience is that VA 
facilities tend to follow the same recruiting process for all types of 
personnel. The same HR systems and processes used to recruit an 
administrative support position are used to recruit a neurosurgeon, 
though the urgency of recruiting a neurosurgeon may be considerably 
greater than the urgency of recruiting other positions. As a third 
party, Merritt Hawkins is unable to contact VA HR personnel to help 
facilitate interviews or help ensure candidates have the information 
they need to make a decision. Moreover, the same person at the VA 
managing the recruitment of administrative personnel also may be 
managing the recruitment of highly trained medical professionals, 
despite the fact that the skill sets required for these two disparate 
tasks vary considerably.
    Without an efficient, timely method for screening, credentialing 
and responding to candidates, the VA is losing well qualified and 
motivated physicians and other professionals to employers who do have 
such systems in place.
    This is particularly unfortunate as the VA offers a style of 
practice that is appealing to many of today's physicians. The VA 
typically offers set hours, generous vacation times, the security of 
government employment, an absence of reimbursement and other practice 
management challenges physicians face in the private sector, freedom 
from the stress of malpractice, a rewarding sense of mission and 
various attractive locations. Many physicians are not aware of this, as 
a stigma about VA practice still is prevalent among some doctors, but 
these perceptions can be overcome. Indeed, none of the key physician 
recruiting challenges facing the VA are related to an inability to 
persuade candidates to accept VA employment. The key challenges lie in 
candidate sourcing and processing.

Compensation and Incentives

    It also may be necessary for the VA to allocate resources to 
enhance physician compensation packages. In the private sector, base 
salaries for primary care physicians, including family physicians and 
internists, average approximately $200,000, not including signing 
bonuses, production bonuses, relocation allowances, and benefits. At VA 
facilities, compensation for primary care physicians varies, but can be 
considerably less than what is common in the private sector. In 
addition, due to VA policies, it often is difficult to be clear with 
candidates regarding the level of compensation being offered. Primary 
care salaries may start with a baseline of $70,000, which immediately 
creates a negative impression, then move up base on merits, but 
obtaining clarity on compensation often is difficult.
    When an offer is made, there are many logistical obstacles in place 
before an offer letter or other documentation confirming the offer/
terms can be obtained, which can undermine the process.
    While VA physician salaries may never equal those to be found in 
the private sector, and it is not necessary that they do so given the 
other incentives the VA can offer, it is important that they at least 
be competitive in today's evolving physician market. It also is 
necessary to communicate effectively to candidates that VA 
opportunities have advantages that make them attractive even if 
salaries are not always commensurate to those in the private sector.

Statement Regarding the Draft Bill

    The draft legislation to improve the authority of the Secretary of 
Veterans Affairs to hire and retain physicians and other employees 
dated February 26, 2016 includes new language that appears to address 
some of the VA's physician recruiting challenges cited above.
    In particular, Section 15 (B) ``Information on Hiring 
Effectiveness'' includes language that addresses the need for ``special 
hiring authorities and flexibilities to recruit most qualified 
applicants.'' Though these authorities and flexibilities are not 
defined, we take this language to mean appropriate personnel at the VA 
will be given the authority to reduce candidate processing times and 
needed clearances and possibly reduce the number of individuals who now 
currently vet physician candidates. We see increased flexibility in VA 
recruiting processes as an essential step in allowing the VA to become 
more nimble in response to a market where physicians are receiving 
multiple job offers and commonly move on if not communicated within a 
timely manner.
    We also believe the language in Sec. 15 (G) authorizing the capture 
of data regarding ``the length of time between the date on which a 
first offer of employment for a position is made and the date on which 
a new hire starts in the position'' is constructive. This will allow 
the VA to track its relative success in reducing candidate processing 
times and increasing process flexibility and effectiveness.
    Similarly, Sec. 15 (I) in which the legislation mandates that the 
VA track ``the number of offers accepted compared to the number of 
offers made for permanent positions'' may have the constructive outcome 
of allowing the VA to measure its recruiting success internally and 
compared to private sector standards. Tracking this data should help 
determine whether the VA is, in fact, becoming more nimble in its 
candidate vetting processes and therefore securing a higher percent of 
candidates to whom it has made offers.
    Further positive new language is included in Sec. 15 (3) in which 
the VA is charged with tracking the ``Satisfaction of employment 
applicants with the hiring process including.user-friendliness of the 
application process, communication regarding status of application, and 
timeliness of hiring decision.'' Tracking this data will further allow 
the VA to determine if it is streamlining it processes and identify 
barriers that may be preventing it from doing so.
    New language in Sec. 14 regarding a ``General Study on Succession 
Planning'' also may prove useful in requiring VA facilities to be more 
proactive in their physician recruiting, anticipating needs and 
marshalling the resources needed to address them on the front end. This 
strategy has proven effective for many of the private sector healthcare 
facilities with which Merritt Hawkins works.
    Not currently addressed in the draft legislation is the need to 
reassess physician compensation amounts and structures in order to put 
VA facilities on a more equal footing with the private sector 
facilities with which they compete.
    In addition, language may be needed to more clearly define the VA 
personnel assigned to the task of physician recruitment and their 
required training. In today's market, ``physician recruiter'' is a 
specialized position and the great majority of private sector hospitals 
(excluding some Critical Access Hospitals) use both in-house physician 
recruiting personnel dedicated to that activity and outside resources 
such as recruiting firms like Merritt Hawkins. The skill set and 
knowledge level needed to recruit physicians, as noted above, is 
different from those needed to recruit other types of personnel.
    Merritt Hawkins also recommends that the draft legislation (or 
implementing regulations) more specifically define how physician 
candidates will be processed throughout the recruiting effort, 
specifying who the decision makers are (and limiting their number) and 
the time frame in which they are required to turnaround candidate 
applications.

CONCLUSION

    As stated in our December, 2015 Statement of Record, while the 
institutional challenges the VA is facing in physician recruitment are 
daunting, they are not confined to the VA. Academic medical centers and 
increasingly large and consolidated healthcare systems in the private 
sector also struggle with implementing streamlined systems for 
processing physician candidates. The healthcare facilities that are 
able to do so are the most likely to achieve consistent physician 
recruiting success, which is attainable even in today's rapidly 
evolving healthcare system.

    FOR ADDITIONAL INFORMATION, PLEASE CONTACT:
    TRAVIS SINGLETON
    SENIOR VICE PRESIDENT
    459 09524 091630
    [email protected]

                                 
                     PARALYZED VETERANS OF AMERICA
    Chairmen Benishek and Wenstrup, Ranking Members Brownley and 
Takano, and members of the Subcommittees, Paralyzed Veterans of America 
(PVA) would like to thank you for the opportunity to present our views 
on the pending legislation impacting the Department of Veterans Affairs 
(VA) employment authority. No group of veterans understand the full 
scope of care provided by the VA better than PVA's members-veterans who 
have incurred a spinal cord injury or disease. Most PVA members depend 
on VA for 100% of their care and are the most vulnerable when access to 
health care, and other challenges, impact quality of care. Elements of 
this bill will help ensure that veterans receive timely, quality health 
care and benefits services.
    In order to accomplish VA's strategic goal, ``to be an employer of 
choice in the national labor market,'' VA must be able to recruit and 
retain qualified professionals, and administrative, technical and other 
staffs, by providing competitive compensation, and opportunities for 
professional and technical development. The Association of American 
Medical Colleges estimates the United States will have a shortage of 
130,600 physicians by 2025. Today, the most vulnerable populations, 
including rural communities and veterans with specialty needs are the 
first to feel the effects. While VA recruitment efforts are improving, 
the inexcusably long process it takes to bring an employee onboard 
continue to turn away highly qualified candidates. VA must provide its 
human resources management staff with the resources and training 
necessary to correct these issues.
    Section 2 of the proposed draft bill would eliminate the current 
statutory requirements that the Medical Directors of VA Medical Centers 
(VAMCs) and directors of Veterans Integrated Service Networks (VISNs) 
be a doctor of medicine or dentistry. Rather, it would require they be, 
to the ``extent practicable'' a qualified medical professional. 
Further, it would allow these directors to receive market pay in 
addition to base pay, with the market pay reviewed by the secretary on 
a case by case basis. PVA supports any effort intended to recruit and 
retain the highest quality health care providers. Our nation's veterans 
deserve no less than the very best. Congress should also consider other 
incentives, such as child care, flexible scheduling, and continuing 
education.
    In 2004, Congress passed P.L. 108 09445, the ``Department of 
Veterans Affairs Health Care Personnel Enhancement Act.'' The act was 
intended to aid VA in recruitment and retention of VA physicians, 
especially scarce subspecialty practitioners, by authorizing VA to 
offer highly competitive compensation to full-time physicians oriented 
to VA careers. VA has fully implemented the act, but PVA suspects the 
act may not have been sufficient enough. PVA urges Congress to provide 
oversight and to ascertain whether VA has adequately implemented its 
intent in enacting P.L. 108 09445.
    Section 3 would allow the Secretary to modify the hours of 
employment for personnel of VHA so they can have more or less than 80 
hours in a biweekly pay period as long as their total hours per 
calendar year do not exceed 2,080 hours. PVA supports this 
modification. Currently, VA emergency room physicians work inflexible 
12-hour shifts within the required 80 hours per pay period that denote 
full-time status. This rigidity does not exist in the private sector. 
Irregular work schedules are needed to provide high quality patient 
care. Additionally, the Veterans Health Administration (VHA) antiquated 
system interferes with recruitment and retention efforts.
    Section 4 would allow the Secretary to pay for 66 percent of the 
Yellow Ribbon Program under the Post-9/11 G.I. Bill for a graduate 
degree in the mental health field as opposed to only ``up to 50 
percent.'' The applicant would have to be eligible for the Post-9/11 
G.I. Bill and eligible for the Yellow Ribbon Program and intend to 
become a mental health professional for VA. PVA supports this 
provision.
    Currently, the Veteran Access Choice and Accountability Act 
requires the VA Office of Inspector General (VAOIG) determine annually 
the five occupations within VHA that had the highest staff shortages. 
Section 5 of this draft would require the VAOIG to evaluate staffing 
shortages for five clinical occupations and five nonclinical 
occupations within each VISN. PVA supports this provision as it would 
add clarity to the staffing capacity where care is directly provided.
    Section 6 would repeal the compensation panels to determine market 
pay for physicians and dentists. PVA currently has no official position 
on this provision.
    Section 7 would require the Secretary to select at least 18, but no 
more than 30, employees to participate in a one year fellowship with a 
private sector company or entity that administers or delivers health 
care or other services similar to those provided within VBA and VHA. 
PVA generally supports this idea. In the current environment there 
could be a benefit to sending VA senior executives into the private 
sector to better understand best practices from both sides. At the same 
time, sending already limited resources and talent outside of VA could 
further undermine the existing training programs within the Department.
    Section 8 would require the Secretary to conduct an annual 
performance plan of VA's political appointees. The plan would be 
similar to those employees who are members of the Senior Executive 
Service and would assess recruitment and retention of qualified 
employees, engagement and motivation, and performance and 
accountability. While surprised there is not already a performance plan 
for VA political appointees, PVA considers this a reasonable provision.
    Section 9 would expand veterans preference to reservists by 
counting their cumulative service rather than consecutive. PVA supports 
offering the preference in hiring to those not currently eligible and 
hopes such an expansion would allow VA to hire more veterans.
    Section 10 would allow the Secretary to noncompetitively reappoint 
a former VA employee to any position within the Department as long as 
the position is not more than one grade higher than their former 
position and as long as the employee left the Department voluntarily 
within the prior two years and maintained necessary licensures and 
credentials. PVA has concerns about bringing back a former employee to 
a higher grade through a noncompetitive process. Such a hiring pathway 
allows for personal relationships to dictate placement. While PVA 
supports the intent to easily fill critical vacancies, we are not 
convinced hiring former employees through a noncompetitive process is 
the most appropriate.
    Section 11 would require the Secretary to create a single 
recruiting database to list any vacant positions the Secretary 
determines are critical to the mission of VA, or difficult to fill, or 
both. It would keep information on applicants not selected for initial 
positions but who are qualified for other positions in the department. 
The Secretary would be required to use the database to fill any vacant 
positions. PVA does not believe a recruiting database is necessary. 
Given the current condition that is VA and its relationship to IT, we 
are unsure how the creation of a new apparatus will quicken the 
Department's efficiencies. Presumably, the `mission critical' positions 
the proposed database would house are currently residing in the 
existing system, if not USAJobs.gov. Why these are not suitable means 
for discovering their listing we would wish to know before offering a 
final opinion.
    PVA generally supports Section 12 that would require the Secretary 
to provide the proper training for human resources (HR) professionals 
for recruiting and hiring Title 38 employees within VHA. Currently, 
most HR professionals are primarily trained for hiring under Title 5, 
while a majority of VHA's hiring is for Title 38 employees. VA must 
reduce the amount of time it takes to bring new employees on board and 
provide its HR staff with adequate support through updated hiring 
processes and proficiency training. The development and implementation 
of defined goals for recruitment and retention (to include promotions, 
continuing education, etc.) should be components of HR staff's 
performance plans. VA HR management staff are not accountable to direct 
service providers. PVA believes they should be held accountable. HR 
performance is not measure by the degree to which they meet hiring and 
recruitment goals. As a consequence, failure to fill a critical vacancy 
in a timely manner carries no adverse effect on the involved HR staff.
    PVA thanks the Subcommittees for their work to recruit and retain 
excellent employees at VA. However we are unsure how all of the aims of 
this draft bill would be meeting the needs of the Department. This 
concludes PVA's statement for the record. We would be happy to answer 
any questions for the record that the Committee may have.
Information Required by Rule XI 2(g)(4) of the House of Representatives
    Pursuant to Rule XI 2(g)(4) of the House of Representatives, the 
following information is provided regarding federal grants and 
contracts.
                            Fiscal Year 2016
    Department of Veterans Affairs, Office of National Veterans Sports 
Programs & Special Events - Grant to support rehabilitation sports 
activities - $200,000.
                            Fiscal Year 2015
    Department of Veterans Affairs, Office of National Veterans Sports 
Programs & Special Events - Grant to support rehabilitation sports 
activities - $425,000.
                            Fiscal Year 2014
    No federal grants or contracts received.
                     Disclosure of Foreign Payments
    Paralyzed Veterans of America is largely supported by donations 
from the general public. However, in some very rare cases we receive 
direct donations from foreign nationals. In addition, we receive 
funding from corporations and foundations which in some cases are U.S. 
subsidiaries of non-U.S. companies.

                                 
                       DISABLED AMERICAN VETERANS
                           ADRIAN M. ATIZADO
    Mr. Chairman and Members of the Subcommittees:
    Thank you for inviting DAV (Disabled American Veterans) to submit 
testimony for the record to discuss our views on draft legislation 
aimed at improving the authority of the Secretary of Veterans Affairs 
(VA) to hire and retain physicians and other VA employees. As you know, 
DAV is a non-profit veterans service organization comprised of nearly 
1.3 million wartime service-disabled veterans and is dedicated to a 
single purpose: empowering veterans to lead high-quality lives with 
respect and dignity.
    According to VA, between FY 2013 and FY 2019, nearly 41 percent of 
the Veterans Health Administration (VHA) workforce will become eligible 
for regular retirement, with over 23 percent projected to actually 
retire. Among senior leaders, the rates of retirement eligibility are 
staggering, with more than 75 percent of the Senior Executive Service 
(SES), Title 38 executives, chiefs of staff, and nurse executives, and 
about half of Associate, Assistant, and Deputy Network Directors 
eligible for retirement within the next 7 years. 1A\1\ This scenario 
highlights the need for this hearing and we applaud the work of both 
Subcommittees' to improve the VA Secretary's authority to recruit and 
retain VA physicians and other employees.
---------------------------------------------------------------------------
    \1\ 1A85.5 percent of SES; 91.2 percent of Title 38 SES; 85.9 
percent of Chiefs of Staff; 77.6 percent of Nurse Grade V; 48.3 percent 
of Associate, Assistant, and Deputy Directors.
---------------------------------------------------------------------------
    Section 2 of this draft bill seeks to address the lack of specific 
authority to make appointments or set rates of pay under title 38 for 
VA Medical Center Director and Network Directors.
    It appears that pay for these directors would be based on the 
methodology of a compensation system similar to that which is used for 
VHA physicians and dentists (38 U.S.C. Sec.  7431) P.L. 108 09445. 
Notably, changes to the VHA physicians and dentists compensation system 
is proposed in Section 6 of this bill. We draw the Subcommittees' 
attention to our comments and concerns on Section 6 as it applies to 
Section 2 of this measure.
    Section 3 would align VA practice with the private sector, 
facilitating the recruitment and retention of emergency physicians and 
the recruitment, retention and operation of a hospitalist physician 
system in VA medical centers.
    To accommodate the need for continuity of efficient hospital care, 
emergency medicine (EM) physicians often work irregular schedules. This 
measure would modify the hours of employment for a full-time physician 
or physician assistant to more or less than 80 hours in a biweekly pay 
period provided the employee's total hours of employment in a calendar 
year would not exceed 2,080. Consequently, VA medical centers would 
gain the ability to implement flexible physician and physician 
assistant work schedules that could accommodate hospitalist and EM 
physicians' schedules and practices.
    DAV does not have a resolution calling for this specific 
legislation; however, because of the measure's beneficial nature, we 
would not oppose its favorable consideration.
    As part of the ``Yellow Ribbon G.I. Education Enhancement 
Program,'' Section 4 of the bill would require the VA Secretary to 
carry out a program in partnership with an institution of higher 
education (IHE) and agree to cover the full cost not covered by the 
post-9/11 G. I. Bill incurred by veterans who are pursuing advanced 
degrees in the mental health field at the IHE and intend to seek 
employment as mental health professionals in VA.
    DAV Resolution No. 122 calls on Congress and VA to establish 
scholarships for future VA mental health practitioners. We are pleased 
to support this important provision which seeks to make program 
improvements related to suicide prevention and would improve access to 
appropriate mental health services for service members and veterans who 
need such services.
    Section 5, would add to the five clinical occupations an additional 
five nonclinical occupations for which the Office of Inspector General 
(OIG) must annually determine are the largest staffing shortages 
throughout the Department as calculated over the five-year period 
preceding the determination.
    We urge the Subcommittee include in this context of determining 
capacity of the VA health care system other directly related factors 
such as space shortages and requirements to meet the goals of the 
Secretary for timely access to care for veterans.
    Section 6 would eliminate the compensation panel recommendation 
process required under 38 U.S.C. Sec.  7431(c)(4)(B) to determine 
market pay for physicians and dentists. We understand that VA believes 
the current compensation panel process is time consuming and yields no 
additional value to other reviews conducted prior to the appointment.
    We understand the ability for the Secretary to exercise 
flexibilities in pay is a vital recruitment and retention tool. The 
Secretary today has discretion over two components of compensation for 
VA physicians and dentists under the title 38 pay system - market pay 
and performance pay. Market pay combined with basic pay (which set by 
law) is meant to reflect the recruitment and retention needs for the 
specialty of assignment of the particular physician or dentist in a VA 
facility. Performance pay, which the Secretary also has discretion 
over, is a statutorily authorized element of annual pay paid to 
physicians and dentists for meeting goals and performance objectives. 
Furthermore, Congress has granted VA other pay flexibilities involving 
discretion, including premium pay, on-call pay, alternate work 
schedules, Baylor Plan, special salary rates, and recruitment and 
retention bonuses.
    It appears that market pay is the only part of VA compensation that 
is determined through a peer-review process composed of a group of 
physicians and/or dentists and based on factors such as the prospects 
experience, qualifications, complexity of the position and difficulty 
recruiting for the position. There is risk eroding the effectiveness of 
market pay by eliminating this role without assurances that the local 
peer-perspective, which ensures consistency and appropriateness of pay 
proposals, will continue to be an important part of the approving 
official's final decision.
    Section 7 would establish a one-year fellowship program to provide 
private sector claims processing training and experience for certain 
Veterans Benefits Administration (VBA) and VHA executives. The private 
sector entity would be engaged in the administration and delivery of 
health care or other services similar to the benefits administered by 
the Secretary.
    We note that the eligible employer under this section of the bill 
would be both VBA and VHA. However, the agreement under the proposed 
new Section 721(e) between VA and the fellow is incongruous, which 
appears to afford the opportunity for employment only in VBA and not 
VHA, which we urge the Subcommittee to correct.
    Section 8 proposes a new requirement for the Secretary to conduct 
an annual performance plan for political appointees within the 
Department similar to the annual performance plan conducted for a 
career VA Senior Executive Service appointee.
    Delegates to our most recent National Convention approved 
Resolution No. 214, calling for the imposition of meaningful employee 
accountability measures in VA, but with due process for employees 
targeted for such sanctions. This section meets the intent of DAV's 
resolution; therefore, DAV supports enactment.
    Section 9 would modify veterans' preference in hiring for 
employment in the federal government by including in the active duty 
service requirement those veterans who have performed 180 days of 
cumulative service and all military retired. The application of such 
preference would also extend to the hiring of senior executive 
positions in the VA.
    DAV supports this provision based on Resolution No. 130, calling, 
for among other things, a broader utilization of veterans and service-
disabled veterans hiring preferences and supporting federal, state and 
local veterans' preference laws.
    Section 10 would allow the Secretary to noncompetitively appoint a 
qualified former employee to any position within the competitive or 
excepted service positions that is one grade higher than the grade of 
the position at the Department most recently occupied by the employee. 
A former employee may not be appointed to a position that is more than 
one grade (or equivalent) higher than the position at the Department 
most recently occupied. The term ``qualified former employee'' means 
any individual who formerly occupied any VA position within 2 years 
before applying for re-employment at the Department; voluntarily left 
such position, or was subject to a reduction in force, and had a 
satisfactory performance record while occupying such position; and 
since leaving such position has maintained relevant licensing 
requirements, if any, and gained skill, knowledge, or other factors 
related to the position.
    Section 11 would authorize the establishment of a single database 
that lists each vacant position in the VA that the Secretary determines 
is critical to the mission of the Department, difficult to fill, or 
both. If an applicant for a vacant position listed in the database is 
qualified but is not selected for the position, the Secretary, at the 
election of the applicant, shall consider the applicant for other 
similar vacant positions listed in the database for which the applicant 
is qualified.
    Section 12 would require VA human resources professionals training 
on how to best recruit and retain Title 38 employees, including any 
recruitment and retention matters that are unique to the VHA. The 
training would be provided in a manner deemed appropriate in light of 
budget, travel, and other constraints. The Secretary shall ensure that 
each VHA human resources professional receives the training as soon as 
practical after being hired as a human resource professional; and 
annually thereafter.
    Section 13 would require VA to establish a promotional track system 
for VA employees determined to be technical experts within one year of 
it being enacted. The developed promotional track would provide 
qualifying employees the opportunity to advance within VA without being 
required to transition to a management position; it would provide for 
the establishment of new positions within VA; and notwithstanding any 
other provision of law, would provide for increases in pay.
    DAV does not have a resolution calling for the provisions in 
sections 10 through 13.
    Section 14 would require the Government Accountability Office to 
conduct a study on the succession planning at each VA medical facility, 
the VBA, and the National Cemetery Administration. For each entity, the 
study must include: A determination of the mission-critical positions 
and the vacancy risk of such positions; An analysis of the future needs 
for mission critical positions and gaps within the existing talent pool 
of the entity; A description of strategies to close skill gaps through 
the use of training for existing staff, targeted recruitment, and 
hiring; A plan to regularly evaluate progress of staff and update 
existing succession plans using clear and measurable metrics and 
benchmarks; A demonstration of the capacity to execute succession plans 
with successful succession management strategies, and; Any other 
matters the Comptroller General determines appropriate.
    The Comptroller General shall submit a report detailing each study 
conducted to the House and Senate Committees on Veterans' Affairs no 
later than one year after enactment.
    We thank the Subcommittees attention to address one of VA's most 
significant challenges is dealing effectively with succession an 
succession planning-especially in the health sciences and technical 
fields that so characterize contemporary American medicine and 
healthcare delivery.
    Section 15 would require the VA to measure and collect detailed 
information on indicators of hiring effectiveness including 
satisfaction of employment applicants and new hires. Personally 
identifiable information of applicants and employees will be kept 
private. The Secretary will submit a report of information collected to 
the House and Senate Committees on Veterans' Affairs, and will annually 
make the information collected publicly available in a consistent and 
machine-readable format to allow for a comparison of hiring 
effectiveness and experience by VISN or comparable public or private 
sector organization.
    DAV has been calling attention to VA's human resources policies, 
which in recent hearings on VA mental health in the Senate, confirm 
that the lack of responsiveness of human resources offices and 
management policies are contributing to deficits in VA's mental health 
programs. Sadly, unresponsive human resources practices are also 
affecting all of VA's key missions. While we believe the collection of 
this information may be useful, we urge the Subcommittee to carefully 
examine VA and Office of Personnel Management appointment authorities 
in statute and how they are being applied within VA to determine 
whether additional legislation would offer any helpful resolution. VA 
should develop and track measures of performance in human resources 
recruitment, on-boarding and retention of clinical staff. Almost as 
important, the Committee should provide targeted oversight in examining 
why VA human resources programs are so weak and unaccountable at a time 
when they should be acting forcefully and supportively to ensure VA 
programs in VHA, VBA and Memorial Affairs are properly staffed to meet 
their missions. With help from Congress, we believe this aspect of VA's 
challenges can be solved with better leadership and more 
responsiveness, beginning at the local level and extending throughout 
the system.
    Section 16 VA would allow for excepted service appointments of 
students and recent graduates leading to conversion to career or career 
conditional employment of a student or recent graduate of a qualifying 
educational institution. The conversion authority shall be applicable 
to individuals in good standing who are employed in a qualifying 
internship or fellowship program at the Department; are employed in the 
Department in a volunteer capacity and performing substantive duties 
comparable to those of individuals in internship or fellowship programs 
and meet the required number of hours for conversion; or who are 
employed in the Department under a contract or agreement with an 
external non-profit organization and performing substantive duties 
comparable to those of individuals in internship or fellowship 
programs.
    DAV has no resolution on this specific provision; however, we 
continue to hear from VA medical facility leaders on too many lost 
opportunities due to the lengthy hiring process for medical students 
who train in VA. As these medical professionals train in VA, they gain 
institutional knowledge, which becomes and tremendous advantage in 
successful transition. Thus, we would not oppose the favorable 
consideration of this section in this regard.
    Section 17 would require VA develop and carry out a standardized, 
anonymous, and voluntary exit survey to be completed by career and non-
career employees and executives of the Department who voluntarily 
leave. Data collected will be anonymized and personally identifiable 
information will be removed, and the results of the survey would be 
shared annually with directors and managers of VA facilities and the 
VISN. Within one year after the date of the enactment, and annually 
thereafter, the Secretary will submit a report containing the aggregate 
results of the exit survey to the House and Senate Committees on 
Veterans' Affairs.
    DAV does not have a resolution calling for this section of the 
bill.
    Mr. Chairman and Members of the Subcommittees, this concludes DAV's 
testimony. We appreciate the invitation to submit testimony for the 
record, and are prepared to respond to any questions on the positions 
we have taken with respect to the bill under consideration.

                                 
                IRAQ AND AFGHANISTAN VETERANS OF AMERICA
                            Lauren Augustine
    Chairman Wenstrup, Chairman Benishek, Ranking Members Takano and 
Brownley, and Distinguished Members of the Subcommittees, on behalf of 
Iraq and Afghanistan Veterans of America (IAVA) and our more than 
450,000 members and supporters, we would like to extend our gratitude 
for the opportunity to share our views on the draft legislation to 
improve hiring practices at the Department of Veterans Affairs (VA).
    As all in the veteran community are well aware, the need for 
greater accountability at the VA is paramount to successfully restoring 
veterans' trust in the system. However, just as important is the need 
to employ and retain highly qualified, motivated professionals willing 
to support the VA's mission. The VA has asked for, and should receive, 
many of the provisions within this draft legislation, which are 
necessary changes to their current hiring practices to support such 
goals. IAVA is pleased to see many additional provisions within the 
draft legislation that aim to meet those same needs among other key 
changes to better the VA's hiring and retention process.
    While the vast majority of VA employees serve veterans with 
outstanding care and professionalism, the few underperforming or 
negligent employees that discredit their service must be held 
accountable in a swift manner that brings justice to the system while 
also protecting whistleblowers and maintaining a culture professionals 
want to work within. IAVA fully supports the measure within the draft 
legislation to appoint Directors of Veterans Integrated Service 
Networks (VISN) and Veterans Affairs Medical Centers (VAMC) under title 
38, which has been requested specifically by the VA, to ensure less 
bureaucracy and more accountability as it relates to disciplining 
wrongdoing. This measure will also provide the VA greater flexibility 
in offering competitive pay and compensation to attract and retain the 
most qualified candidates for such positions. We cannot expect VA 
Directors to perform at levels that meet or exceed their private-sector 
counterparts if we are not willing to compensate them fairly.
    Additional contributions to greater accountability in the 
legislation require the VA to conduct an annual performance plan for 
all political appointees in a similar manner Senior Executive Service 
are evaluated. The evaluation would include measuring appointees' 
ability to recruit and retain qualified employees, engage and motivate 
employees, train employees and hold them accountable for any potential 
performance issues. The ability for all VA leaders, including political 
appointees, to successfully meet and exceed the requirements of such 
tasks will continue to be a key aspect to ensuring quality leaders 
exhibit the highest standards of professionalism.
    In its efforts to institute better hiring practices, the VA must 
also become more acutely aware of the actual need and capabilities of 
its workforce in addition to instituting policies to support its 
existing workforce. IAVA supports the measures within the draft 
legislation to provide the VA better insight its hiring capabilities. 
Specifically, IAVA supports the requirement to measure and collect 
information on hiring effectiveness and to adjust the current 
requirements to identify the five occupations with the highest staffing 
shortages to include the five highest staffing shortages for both 
clinical and nonclinical occupations. Understanding what the staffings 
needs are coupled with a greater understanding of hiring effectiveness 
will help streamline the process for those looking to serve within the 
VA. Building on that is the need to ensure continued training and 
growth opportunities for existing VA employees. The promotional track 
for technical experts that eliminates a requirement to accept 
managerial positions created within the legislation will help retain 
those professionals looking to utilize their expertise without adding 
unwanted responsibilities. Leveraging the existing expertise and talent 
within the VA supports a greater continuity of institutional knowledge 
and professional satisfaction.
    Providing professional development and training opportunities for 
VA employees are practices IAVA has frequently advocated for as a means 
to support the VA workforce. As such, IAVA strongly supports the one 
year private-sector fellowship for select Veteran Benefits 
Administration (VBA) and Veterans Health Administration (VHA) 
employees. Gaining best-in-practice knowledge, policies and procedures 
from the private sector can only help strengthen the capabilities of VA 
employees and their capacity to meet the VA's mission. Likewise, IAVA 
supports the provision to provide training for human resources 
professionals within the VA for recruiting and hiring Title 38 
employees. Since Title 38 employees make up many of the occupations 
with the VHA, understanding the nuances of the hiring process for these 
employees will create a more efficient process.
    The provisions within the draft legislation that consider 
adjustments to education benefits through the Yellow Ribbon program and 
modifications to veteran preference are both measures IAVA supports as 
a means to increase both the number of applicants seeking to serve at 
the VA and the number of veterans serving within the VA system. IAVA is 
particularly supportive of incentivizing veterans to seek education 
that will lead to becoming mental health care professionals within the 
VA. As our members continue to express a need for greater access to 
care and cultural understanding, IAVA recognizes the potential of such 
incentives will help meet that need.
    At IAVA, we believe our members, and all veterans, deserve the very 
best our nation can offer when it comes to fulfilling the promises made 
to them upon entry into the military. To support that cause and the 
critical mission of the VA, IAVA fully supports equipping the VA with 
the necessary authority to provide best-in-class hiring practices.
    As the Committee works to finalize this legislation, IAVA strongly 
recommends not paying for its provisions by cutting critical benefits 
that our nation's 23 million veterans and their families have come to 
rely upon. We look forward to reviewing the final language of the 
legislation, continuing to work together as partners, and finding 
veteran-centric solutions to the challenges facing the VA and the 
veteran community.

                                 
                      RESERVE OFFICERS ASSOCIATION
    The Reserve Officers Association of the United States (ROA) is a 
professional association of commissioned, non-commissioned and warrant 
officers of our nation's seven uniformed services. ROA was founded in 
1922 by General of the Armies John ``Black Jack'' Pershing during the 
drawdown years following the end of World War I. It was formed as a 
permanent institution dedicated to national defense, with a goal to 
inform America regarding the dangers of unpreparedness. Under ROA's 
1950 congressional charter, our purpose is to promote the development 
and execution of policies that will provide adequate national defense. 
We do so by developing and offering expertise on the use and resourcing 
of America's Reserve Components.
    The association's members include Reserve and Guard Soldiers, 
Sailors, Marines, Airmen, and Coast Guardsmen who frequently serve on 
active duty to meet critical needs of the uniformed services. ROA's 
membership also includes commissioned officers from the United States 
Public Health Service and the National Oceanic and Atmospheric 
Administration who often are first responders during national disasters 
and help prepare for homeland security.
    President: Col. James R. Sweeney II, USMC (Ret.) 202 09646 097706
    Executive Director: Jeffrey E. Phillips 202 09646 097726
    Legislative Director: Lt. Col. Susan Lukas, U.S. Air Force Reserve 
(Ret.) 202 09646 097713

DISCLOSURE OF FEDERAL GRANTS OR CONTRACTS

    The Reserve Officers Association is a member-supported 
organization. ROA has not received grants, contracts, or subcontracts 
from the federal government in the past three years. All other 
activities and services of the associations are accomplished free of 
any direct federal funding.

STATEMENT

    ROA appreciates the opportunity to discuss proposed legislation for 
improving the authority of the Secretary of Veterans Affairs to hire 
and retain physicians and hire Guard and Reserve members. This 
statement addresses a legislative priority developed by ROA as a result 
of feedback from ROA members and Reserve Component service members.

SEC. 9. MODIFICATION TO VETERANS PREFERENCE

    The Reserve Officers Association urges Congress to support SEC. 9. 
MODIFICATION TO VETERANS PREFERENCE, which changes title 5, USC 
2108(1)(B) and (D) to strike the word ``consecutive'' and change it to 
``cumulative'' in each instance.

Reserve Component Participation

    During the present war, nearly a million Guard and Reserve members 
have been mobilized, proving essential to the war effort. The reliance 
of the nation on its Reserve Components will not diminish.
    Since September 11, 2001, more than 900,000 members of our reserve 
components - the National Guard and Reserves of our Army, Navy, Air 
Force, Marines and Coast Guard - have served in support of the war on 
terrorism. More than 1,200 have died in that fight.

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]



    ``War is a national challenge, and, for our part, we cannot execute 
without the Guard and the Reserve,'' said Army Chief of Staff Gen. Mark 
Milley. You can't talk to a general or admiral for more than five 
minutes without hearing a variation on that theme.
    The chart below shows that the Guard and Reserve have been used in 
increasingly higher amounts per year. While usage is dropping it will 
not go down to previous peacetime levels because threats to the nation 
and world have increased.

                     Usage of the Reserve Components
------------------------------------------------------------------------
            Fiscal Year                       Man-Days Per Year
------------------------------------------------------------------------
                       1986 091989                            1 million
------------------------------------------------------------------------
                       1996 092001                           13 million
------------------------------------------------------------------------
                              2002                         41.3 million
------------------------------------------------------------------------
                              2005                         68.3 million
------------------------------------------------------------------------
                              2012                         25.8 million
------------------------------------------------------------------------
Data from the Office of the Assistant Secretary of Defense for Reserve
  Affairs (OASD/RA).


Background

    According to Jeff Phillips, ROA Executive Director, in a recent op-
ed, ``It was over my first Philly cheesesteak sandwich - in 
Philadelphia - that I learned Maj. Bonnie Carroll was not a veteran 
despite her extraordinary service to our country.''
    Reservists today serve virtually everywhere, alongside their 
``active component'' comrades. In battle, the performance of these 
trained and courageous citizen-warriors of all ranks, specialties, and 
any other category has been recognized as indistinguishable from the 
``regulars.'' They ask to serve; they deserve equity for that service.
    Inequity is written into law; most of the legislation governing the 
military was written before and during the Cold War. The reserves in 
those days were a strategic reserve and not used much - that's where 
the ``one weekend per month and two weeks in the summer'' model 
evolved.
    Desert Shield, Desert Storm and the present war changed all that. 
The reserves are now considered ``operational.'' They are used 
continually, like the active force. In the late 1980s, usage of the 
reserves was 1 million man-days per year; it is now about 25 million 
man-days. But the law hasn't kept up as important benefits are limited 
only to those who serve in ``active military, naval, or air service.''
    By ``important benefits,'' we are talking about who you are in the 
eyes of federal law when it comes to being considered for hiring 
preferences accorded to veterans.
    We are talking about helping young, dynamic new professionals - who 
understand service and dedication to higher cause - renew our graying 
and often hidebound federal bureaucracy.
    Bonnie stunned me when she told me she wasn't a veteran.
    ``But, of course you are, you've served in the Air Force,'' I 
countered, momentarily forgetting my cheesesteak sandwich.
    No, she told me, she had never amassed enough days on ``active 
duty'' to qualify to be a veteran under titles 5 and 38 for federal 
hiring preference. To be a veteran for hiring preferences, she needed 
180 or more consecutive days on active duty - and that did not include 
active duty while she was training. In those days, getting nearly six 
consecutive months on active duty was tough.
    As the operational tempo of the recent past changes and fewer 
members of the Guard and Reserve deploy (a situation that will last 
only until the next war) achieving 180 or more consecutive days on 
active duty will become even more difficult. But it will always be much 
more likely for these reservists to amass 180 or more cumulative days 
on active duty. Inequity is an enduring theme unless we make this 
simple change.
    Both the Department of Veterans Affairs and the top leaders of our 
reserve forces informally indicated to ROA there is no cost and they 
would not object to such a change the law.
    Recent legislation sought to grant ``honorary'' veteran status to 
reservists with 20 or more years of service - legislation ROA 
supported. These reservists are a fraction of the whole. We are here 
urging a simple reform that would substantively help the vast majority 
of reservists who are still serving as citizen-warriors or who 
separated before military retirement.
    Changing one word would provide significant equity to members of 
our Guard and Reserve who affirm the wisdom of our founders in their 
willingness to serve boldly, selflessly, and with great fidelity in the 
defense of our way of life. They balance military service - a consuming 
and uncompromising business - with the demands of a civilian work life 
and the care of their families.
    According to SGM (Ret) Frank Yoakum, Executive Director, EANGUS, 
``Major Bonnie Carroll (retired) is one of thousands of National Guard 
and Reserve retirees who were part of the 1% of America who served in 
our military--not only served, but gave a lifetime of service--only to 
find out that our Congress and our government, based on a technicality, 
does not consider them veterans. In their careers, they were available 
to go to war; they were trained to go to war; they were ready to go to 
war; but the timing and placement of their service placed them in 
support but not direct warfight roles. They should not continue to be 
penalized for exemplary service. The time is now; the technical change 
is simple; the personal reward and thanks of a grateful nation is 
priceless. We strongly encourage Congress to do the right thing and 
make this correction to the law on behalf of thousands of retirees who 
really are veterans.''

Unemployment of the Guard and Reserve

    Unemployment during the Gulf War steadily increased higher for 
veterans than nonveterans, especially those from the current war. Of 
that group, 30 percent of both Gulf War-era I and Gulf War-era II 
veterans were reported to be current or past members of the Reserve or 
National Guard.
    ``In 2014, 21.2 million men and women were veterans. Of these, 10.2 
million veterans were employed, 573,000 were unemployed, and the rest, 
10.5 million, were not in the labor force (neither employed nor seeking 
employment).'' http://www.bls.gov/opub/ted/2015/veteran-unemployment-
decreases-in-2014.htm
  unemployment rates of persons 18 years and over by veteran status, 
   period of serivce, sex, race, and ethnicity, 2014 annual averages
   
   
 [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
  

    As of March 23, 2015

    Since 2014 unemployment overall has decreased, in part because the 
government increased their efforts to hire more veterans in the federal 
government to reduce veteran homelessness. By the end of fiscal year 
2014, the government was able to employ 516,075 veterans out of 
1,990,033 employees. However, most agencies are below the average 
percentage of 25.9 percent once you exclude the Departments of Defense 
and Veterans Affairs (27.4% to 48.5%). The remaining agencies average 
only 13.8 percent

                                                   Total On-Board Employees - Veterans with Preference
--------------------------------------------------------------------------------------------------------------------------------------------------------
                       All Employees                                    Veterans                   with Preference                       %
--------------------------------------------------------------------------------------------------------------------------------------------------------
Agriculture................................................                        95,917                         10,519                          11.0%
Commerce...................................................                        45,380                          4,633                          10.2%
Education..................................................                         4,195                            369                           8.8%
Energy.....................................................                        14,992                          2,879                          19.2%
HHS........................................................                        84,588                          5,714                           6.8%
Homeland Security..........................................                       189,341                         43,736                          23.1%
HUD........................................................                         8,444                          1,142                          13.5%
Interior...................................................                        69,955                         10,203                          14.6%
Justice....................................................                       113,240                         21,751                          19.2%
Labor......................................................                        15,940                          3,093                          19.4%
State......................................................                        12,694                          2,195                          17.3%
Treasury...................................................                        92,619                          8,629                           9.3%
AID........................................................                         1,698                            235                          13.8%
EPA........................................................                        15,852                          1,068                           6.7%
GSA........................................................                        11,501                          2,088                          18.2%
NASA.......................................................                        17,691                          1,555                           8.8%
NSF........................................................                         1,425                             92                           6.5%
OPM........................................................                         4,977                          1,025                          20.6%
NRC........................................................                         3,871                            652                          16.8%
SSA........................................................                        64,684                          8,181                          12.6%
SBA........................................................                         4,549                            677                          14.9%
--------------------------------------------------------------------------------------------------------------------------------------------------------
https://www.fedshirevets.gov/hire/hrp/reports/EmploymentOfVets-FY14.pdf

    Changing the language for federal preference would provide a pool 
of Guard and Reserve veterans for agencies to consider, thereby, 
increasing their veteran hires. In 2012, the Center for New American 
Security released a report, titled, Employing Americans Veterans that 
said, ``Hiring veterans is good business, according to detailed and 
lengthy interviews with 87 individuals representing 69 companies. The 
companies reported 11 reasons they hire veterans, with an emphasis on 
veterans' leadership and teamwork skills, character and discipline...'' 
The reasons include:

     Leadership and teamwork skills. Veterans typically have 
led colleagues, accepted direction from others and operated as part of 
a small team.
     Character. Veterans are perceived as being trustworthy, 
dependable, drug-free and having a strong work ethic.
     Structure and discipline. Companies, especially those that 
emphasize safety, appreciate veterans' experience following established 
procedures.
     Expertise. Companies value veterans' occupational skills, 
job-specific experiences and understanding of the military community. 
http://www.cnas.org/files/documents/publications/CNAS--
EmployingAmericasVeterans--HarrellBerglass.pdf

    These and the other reasons discussed in the report should equally 
apply to why hiring a Guard or Reserve veteran makes sense for the 
federal government.
    Not unlike her citizen-warrior comrades, Bonnie is a remarkable 
woman. Self-effacing and dedicated to the service of others, she asks 
nothing for herself. ROA is urging this reform for today's reservists 
now being shortchanged, and for the benefit of a nation that needs them 
serving the public as civil servants.
    In 1994 Bonnie founded Tragedy Assistance Program for Survivors 
after her husband, an Army officer, was killed in a military plane 
crash. TAPS supports those who have lost a loved one in military 
service, but provides expertise to all who need that kind of help. They 
are known for their unparalleled expertise in the care and recovery of 
survivors.
    For her work with surviving families, President Obama awarded 
Bonnie the Presidential Medal of Freedom in November.
    Maj. Bonnie Carroll ultimately retired after 32 years in both the 
Air National Guard and the Air Force Reserve.
    But according to federal law, she's not a veteran for federal 
hiring benefits and did not get a 5-point preference that would have 
increased her chances to be hired earlier in her career.
    It's time that changed for the men and women serving today.

CONCLUSION

    The Reserve Officers Association, the Enlisted Association of the 
National Guard of the United States and the National Guard Association 
of the United States supports legislation that would extend federal 
preference to the deserving men and women of the Reserve Components.

                                 
                 AMERICAN PODIATRIC MEDICAL ASSOCIATION
              Testimony of Dr. Phillip E. Ward, President
    Chairmen Benishek and Wenstrup, Ranking Members Brownley and Takano 
and members of the Subcommittees, I welcome and appreciate the 
opportunity to submit testimony to you today on behalf of the American 
Podiatric Medical Association (APMA). I commend these Subcommittees for 
their focus to assist and direct the Veterans Administration (VA) to 
effectively and efficiently recruit and retain qualified medical 
professionals to treat veteran patients and improve access to quality 
health care in the VA system by addressing the lengthy and burdensome 
credentialing and privileging process.
    I am Dr. Phillip Ward, member and president of the American 
Podiatric Medical Association (APMA). I represent APMA and the 
podiatric medical profession, and specifically our members currently 
employed, and those seeking to be employed, by VA. While I do not 
represent VA, I do speak for those with first-hand experience and 
knowledge of hiring practices within VA, as well as knowledge of the 
widespread disparity between podiatric physicians and other VA 
physicians.
    APMA is the premier professional organization representing 
America's Doctors of Podiatric Medicine who provide the majority of 
lower extremity care, both to the public and veteran patient 
populations. APMA's mission is to advocate for the profession of 
podiatric medicine and surgery for the benefit of its members and the 
patients they serve.
    Mr. Chairmen, as you know the Veterans Health Administration (VHA) 
qualification standards for podiatry were written and adopted in 1976. 
Podiatric education, training and practices in 1976 starkly contrasted 
with that of other physician providers of the time, and with podiatric 
medicine as it is today. Unlike forty years ago, the current podiatric 
medical school curriculum is vastly expanded in medicine, surgery and 
patient experiences and encounters, including whole body history and 
physical examinations. In 1976, residency training was not required by 
state scope of practice laws. Today, every state in the nation, with 
the exception of four, requires post-graduate residency training for 
podiatric physicians and surgeons. In 1976, podiatric residency 
programs were available for less than 40 percent of graduates. Today 
there are 609 standardized, comprehensive, three-year medicine and 
surgery residency positions to satisfy the number of our graduates, 
with 77 positions (or 13 percent) housed within the VA. In contrast to 
1976, today's residency programs mandate completion of a broad 
curriculum with a variety of experiences and offer a direct pathway to 
board certification with both the American Board of Podiatric Medicine 
(ABPM) and the American Board of Foot and Ankle Surgery (ABFAS). These 
certifying bodies are the only certifying organizations to be 
recognized by the Council on Podiatric Medical Education (CPME) and VA. 
These bodies not only issue time-limited certificates, but they 
participate in the Centers for Medicare and Medicaid Services (CMS) 
Maintenance of Certification (MOC) reimbursement incentive program. 
Unlike the residency curricula in 1976 (which were not standardized, 
nor comprehensive), today's residency curriculum is comparable to MD 
and DO residency training and includes general medicine, medical 
specialties such as rheumatology, dermatology and infectious disease, 
general surgery and surgical specialties such as orthopedic surgery, 
vascular surgery and plastic surgery. CPME-approved fellowship programs 
did not exist in 1976, but since their creation in 2000, they offer our 
graduates opportunities for additional training and sub-specialization. 
Today, podiatric physicians are appointed as medical staff at the vast 
majority of hospitals in the United States, and many serve in 
leadership roles within those institutions, including but not limited 
to chief of staff, chief of surgery, and state medical boards. Many of 
my colleagues have full admitting privileges and are responsible for 
emergency room call as trauma and emergency medicine are now also 
incorporated into post-graduate training. The competency, skill and 
scope of today's podiatric physicians are vastly expanded and truly 
differ from the podiatrist that practiced before 1976. Because of this, 
CMS recognizes today's podiatrists as physicians, and Tricare 
recognizes us as licensed, independent practitioners.
    The total number of VA enrollees has increased from 6.8 million 
in2002 to 8.9 million in 2013 (1). While we are slowly losing our 
Vietnam veteran population, we are gaining a solid base of Operation 
Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) patients, 
returning from war with their unique lower extremity issues. The 
projected patient population of Gulf War Era veterans is expected to 
increase from 30 percent in 2013 to approximately 55 percent in 2043 
(1). The number of service-connected disabled veterans has increased 
from approximately 2.2 million in 1986 to 3.7 million in 2013 (1). Over 
90 percent of disabled veterans were enrolled in VHA in 2012 (1). The 
likelihood of service-connected disabled veterans seeking VA health 
care generally increases with the veteran's disability rating (1). The 
majority of male veterans who are currently seeking care from VA served 
during the Vietnam era (1).
    As a matter of fact, veteran patients are ailing and have more 
comorbid disease processes than do age-matched Americans (2, 3, 4, 5, 
6). This includes major amputation, where age-specific rates are 
greater in the VHA compared to the US rates of major amputation (7). 
Elderly enrolled veterans have substantial disease burden with 
disproportionately poor health status compared to the same age enrolled 
in Medicare (8). The prevalence of diabetes is substantially greater 
among veteran patients compared to the general population, and 
unfortunately, the prevalence is trending up (6). While diabetes 
affects 8 percent of the US population, 20 percent of veteran patients 
carry this diagnosis (9).The aging veteran population combined with 
these increased rates of diabetes has increased the burden of diabetic 
foot ulcers and amputations (10). Veteran patients with one or more 
chronic diseases account for 96.5 percent of total VHA health care (9). 
In addition to diabetes, some of the most common chronic conditions 
documented in our veteran patients manifest in the lower extremity such 
as hyperlipidemia, coronary artery disease, chronic obstructive 
pulmonary disease, and heart failure.(9).
    Socioeconomic and psychosocial issues often plague our veterans and 
further complicate disease management. Veteran patients statistically 
have lower household incomes than non-veteran patients (1). Sadly, many 
of our veterans are homeless and suffer from comorbid conditions such 
as diabetic foot ulcers, sometimes with a level of amputation, so 
management of this patient population can be extremely challenging. 
Health care expenses combined with disability and compensation coverage 
account for the majority of VA utilization and have demonstrated 
significant growth since 2005 (1).
    This is the VA patient population, Mr. Chairman. Our VA provider 
members serve patients who are statistically comorbid with psychosocial 
and socioeconomic issues, all of which play a role in the delivery of 
care and final outcome. I know that the veteran population is far more 
complex to treat than patients in the private sector, as a whole. 
Greater than 90% of the veteran podiatric patient population is 44 
years and older, with the majority of our patients of the Vietnam era, 
who are plagued by the long-term effects of Agent Orange. Because of 
this and because of the increasing number of OEF, OIF, and Operation 
New Dawn (OND) veterans with lower extremity conditions, one of our 
major missions as providers of lower extremity care is amputation 
prevention and limb salvage. The value of podiatric care is recognized 
in at-risk patient populations. Podiatric medical care as part of the 
interdisciplinary team approach reduces the disease and economic 
burdens of diabetes. In a study of 316,527 patients with commercial 
insurance (64 years of age and younger) and 157,529 patients with 
Medicare and an employer sponsored secondary insurance, there was noted 
a savings of $19,686 per patient with commercial insurance and a 
savings of $4,271 per Medicare-insured patient, when the patients had 
at least one visit to a podiatric physician in the year preceding their 
ulceration (11). Nearly 45,000 veterans with major limb loss use VA 
services each year. Another 1.8 million veterans within the VA 
Healthcare Network are at-risk of amputation. These at-risk veterans 
include 1.5 million with diabetes, more than 500,000 with sensory 
neuropathy, and more than 80,000 with non-healing foot ulcers (12). 
Despite having a large at-risk patient population from the Vietnam era, 
VA podiatric physicians are seeing increasing numbers of OEF, OIF and 
OND patients who are at-risk for amputation. Given the magnitude of 
amputation reductions, podiatric physicians not only provide a cost-
savings to VA, but we also play an integral role in the veteran quality 
of life (12).
    While limb salvage is a critical mission of the podiatry service in 
the VA, the care delivered by the podiatric physician is of much 
broader scope. As the specialist of the lower extremity, we diagnose 
and treat problems ranging from dermatological issues to falls 
prevention to orthopedic surgery. As one of the top five busiest 
services in VA, we provide a significant amount of care to our veteran 
patients and the bulk of foot and ankle care specifically. In fiscal 
year 2015, the foot and ankle surgical procedures rendered by the 
podiatry services totaled 28,300, while foot and ankle surgical 
procedures performed by the orthopedic surgery service was a sum total 
of 4,047.
    The mission of VA health providers is to maintain patient 
independence and keep the patient mobile by managing disease processes 
and reducing amputation rates. Podiatric physicians employed by VA 
assume essentially the same clinical, surgical, and administrative 
responsibilities as any other unsupervised medical and surgical 
specialty. Podiatrists independently manage patients medically and 
surgically within our respective state scope of practice, including 
examination, diagnosis, treatment plan and follow-up. In addition to 
their VA practice, many VA podiatrists assume uncompensated leadership 
positions such as residency director, committee positions, clinical 
manager, etc. Examples include:

     Steve Goldman, DPM, Chief of Podiatry and Director of 
Podiatric Medical Education at Department of Veterans Affairs, 
Northport, NY;
     William Chagares, DPM, Research Institutional Review Board 
Co-Chair, Chair of Research Safety Committee and Research Integrity 
Officer and Chair of Medical Records Committee at the James A. Lovell 
Federal Heath Care Center;
     Aksone Nouvong, DPM, Research Institutional Review Board 
Co-Chair at the West Los Angeles VA;
     Lester Jones, DPM the former Associate Chief of Staff for 
Quality at the VA Greater Los Angeles Health Care System for eight 
years, and podiatric medical community representative while serving on 
the VA Special Medical Advisory Group;

    Despite this equality in work responsibility and expectations, 
there exists a marked disparity in recognition and pay of podiatrists 
as physicians in the VA. These discrepancies have directly resulted in 
a severe recruitment issue of experienced podiatrists into the VA, and 
unfortunately have also been the direct cause of retention issues. The 
majority of new podiatrists hired within the VA have stories just like 
these. They have less than ten years of experience and they are not 
board certified. As a result of the disparity the VA is attracting less 
experienced podiatric physicians. After hiring, the majority of these 
new podiatrists that hire into the VA separate within the first 5 
years.
    Compounding the recruitment and retention issues, there exists 
lengthy employment vacancies when a podiatrist leaves a station. The 
gap between a staff departure to the time of filling the position is in 
excess of one year. Because of employment gaps as a consequence of the 
inherent and chronic recruitment and retention challenges, wait times 
within the VA for lower extremity care are unacceptably long. Since 
October 2014, 22,601 of the 191,501 (11.8 percent) established patients 
suffered a wait time of greater than 15 days, with some greater than 
120 days. During this same time period, 23,543 of the 25,245 (93 
percent) new patients suffered a wait time of the same magnitude. The 
prolonged vacancy exists partly because the VA is not capable of 
attracting experienced candidates, but also because the credentialing 
process is ineffectively burdensome. There have been no reported 
improvements in on-boarding since our last testimony was submitted on 
this issue in May of 2015.
    It is precisely because of the aforementioned issues that 
legislative proposals to amend Title 38 to include podiatric physicians 
and surgeons in the Physician and Dentist pay band, have been submitted 
by the Director of Podiatry Services annually for the last ten years. 
These proposals have been denied every single year. Additionally, 
several requests for an internal fix have been denied, despite written 
letters of support for this movement from the former Under Secretary of 
Health, Robert Petzel, MD.
    Six years ago the APMA's House of Delegates passed a resolution 
making this issue a top priority. Since then we have alerted the VA to 
our knowledge of this issue. In response, former Under Secretary Petzel 
created a working group composed of Dr. Rajiv Jain, now Assistant 
Deputy Under Secretary for Health for Patient Care Services, Dr. 
Margaret Hammond, Acting Chief Officer for Patient Care Services, and 
Dr. Jeffrey Robbins, Chief of Podiatry Service. We have participated in 
several meetings with members of the working group and, most recently, 
we have received written support of Patient Care Services and Podiatry 
Service for a legislative solution to address this issue.
    Occam's razor is a problem solving principle whereby the simplest 
solution is often the best. I submit testimony to this committee today 
to respectfully request that Congress help the VA and its patients by 
passing legislation to recognize podiatric physicians and surgeons as 
physicians in the physician and dentist pay band. We believe that 
simply changing the law to recognize podiatry, both for the 
advancements we have made to our profession and for the contributions 
we make in the delivery of lower extremity care for the veteran 
population, will resolve recruitment and retention problems for VA and 
for veterans. Mr. Chairmen and members of the Subcommittees, thank you 
again for this opportunity.

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    12.Preventing Amputation in Veterans Everywhere (PAVE) Program

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