[House Hearing, 114 Congress]
[From the U.S. Government Publishing Office]
OVERCOMING BARRIERS TO MORE EFFICIENT AND EFFECTIVE VA STAFFING
=======================================================================
HEARING
before the
SUBCOMMITTEE ON HEALTH
of the
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED FOURTEENTH CONGRESS
FIRST SESSION
__________
FRIDAY, MAY 15, 2015
__________
Serial No. 114-21
__________
Printed for the use of the Committee on Veterans' Affairs
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Available via the World Wide Web: http://www.fdsys.gov
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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
Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public
hearing records of the Committee on Veterans' Affairs are also
published in electronic form. The printed hearing record remains the
official version. Because electronic submissions are used to prepare
both printed and electronic versions of the hearing record, the process
of converting between various electronic formats may introduce
unintentional errors or omissions. Such occurrences are inherent in the
current publication process and should diminish as the process is
further refined.
C O N T E N T S
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Friday, May 15, 2015
Page
Overcoming Barriers to More Efficient and Effective VA Staffing.. 1
OPENING STATEMENTS
Dan Benishek, Chairman........................................... 1
Julia Brownley, Ranking Member................................... 2
WITNESSES
Joan Clifford MSM, RN FACHE, Immediate Past President, Nurses
Organization of Veterans Affairs............................... 4
Prepared Statement........................................... 37
Samuel V. Spagnolo M.D., President, National Association of
Veterans Affairs Physicians and Dentists....................... 5
Prepared Statement........................................... 39
Jeff L. Morris J.D., Director of Communications and External
Affairs, American Board of Physician Specialties............... 8
Prepared Statement........................................... 47
Rubina DaSilva PA--C, President, Veterans Affairs Physician
Assistant Association.......................................... 10
Prepared Statement........................................... 54
Nichol L. Salvo DPM, Member and Employee, American Pediatric
Medical Association............................................ 12
Prepared Statement........................................... 63
Thomas Lynch M.D., Assistant Deputy Under Secretary for Health
for Clinical Operations, VHA, U.S. Department of Veterans
Affairs........................................................ 27
Prepared Statement........................................... 67
Accompanied by:
Elias Hernandez, Deputy Chief Officer for Workforce
Management and Consulting, VHA, U.S. Department of
Veterans Affairs
And
Donna Gage Ph.D., RN, NE-BC, Chief Officer of Nursing
VHA, U.S. Department of Veterans Affairs
STATEMENT FOR THE RECORD
American Counseling Association.................................. 77
American Federation Government Employees......................... 80
The American Legion.............................................. 93
Partnership for Public Service................................... 98
Merritt Hawkins.................................................. 108
OVERCOMING BARRIERS TO MORE EFFICIENT AND EFFECTIVE VA STAFFING
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Friday, May 15, 2015
U.S. House of Representatives,
Committee on Veterans' Affairs,
Subcommittee on Health,
Washington, D.C.
The subcommittee met, pursuant to notice, at 11:09 a.m., in
Room 334, Cannon House Office Building, Hon. Dan Benishek
[chairman of the subcommittee] presiding.
Present: Representatives Benishek, Roe, Coffman, Wenstrup,
Abraham, Brownley, Takano, Kuster, and O'Rourke.
Also Present: Representative Costello.
OPENING STATEMENT OF CHAIRMAN DAN BENISHEK
Dr. Benishek. The subcommittee will come to order.
Before we begin, I would like to ask unanimous consent for
my friend, colleague, and member of the full committee,
Congressman Ryan Costello from Pennsylvania, to sit on the
dais, participate in today's proceedings.
Without objection, so ordered.
Thank you for joining us today for today's subcommittee
hearing, ``Overcoming Barriers to More Efficient and Effective
VA Staffing.''
As a physician who worked fee-for-service at the Iron
Mountain VA, Department of Veteran Affairs, Medical Center for
about 20 years, I know firsthand how rewarding it can be to
take care of veterans at the VA. And having the privilege of
caring for veterans on a daily basis was really wonderful for
me.
Regardless of how fulfilling VA employment often is, the
Department's ability to effectively and efficiently recruit and
retain qualified medical professionals to treat veterans is
seriously fractured. For example, in my district, the Sault
Ste. Marie Community-Based Outpatient Clinic in Sault Ste.
Marie, Michigan, has not had a physician on staff for at least
2 years.
VA has attributed that to the difficulty of recruiting
physicians in rural areas. And while I understand that
difficulty, I think VA's overly bureaucratic hiring process is
also a significant factor in its inability to recruit a
physician for multiple years running.
The Iron Mountain VAMC, the Sault Ste. Marie CBOC's parent
facility, was unable to post the opening for a physician
directly. Instead, all job postings under Iron Mountain's
purview are filtered through a human resource office in
Milwaukee, Wisconsin, several hours away in another State. In
my understanding, all VISN 12 facility job postings are run
through this one office in Milwaukee.
What is more, despite repeated assurances by VA officials
the Department was actively recruiting for a physician in the
Sault--in Sault Ste. Marie--we call it ``the Sault'' in
Michigan--I have yet to see a single advertisement for that
position besides a blurb on the hospital's Web site, leaving me
to wonder whether the VA knows what effective recruiting is
supposed to look like.
As important as effective recruitment is, effective
retention of existing employees is also critical. But according
to the 2014 Best Places to Work survey published by the
Partnership for Public Service, the number of VA employees
resigning or retiring has risen every year since 2009. And it
is not hard to see why: The survey results rank VA 18 of 19
large agencies overall, 18 of 19 in effective leadership, 19 of
the 19 in pay, with the Department's overall score last year
being the lowest VA has received since the report was first
published in 2003.
When a VA medical center is improperly staffed and when a
qualified candidate chooses to look elsewhere for work or when
an existing provider makes the decision to leave the VA, it is
our veterans that lose out. The growing physician shortage is
causing the healthcare marketplace to become more and more
competitive, with the Association of American Medical Colleges
projecting a 91,000-physician shortfall by 2025.
If the VA is going to keep pace with the private sector in
recruiting and retaining the high-quality providers that our
veterans deserve, immediate action must be taken to improve
retention of existing staff and ensure that qualified
candidates for new or vacant positions are quickly identified,
recruited, hired, and brought aboard.
Critical to that and to all of VA's plans regarding the
delivery and quality of care is making sure that those on the
front lines providing direct patient care are not only involved
but leading the efforts to make the VA healthcare system
stronger.
To that end, I am proud to have representatives from the
National Association of VA Physicians and Dentists, the VA
Physician Assistant Association, and the Nurses Organization of
VA on our first panel of witnesses today.
The input you as well as the rest of our witnesses will
provide about the daily reality you and your members face at VA
facilities across the country every day is invaluable. I thank
you and all of our witnesses for being here this morning.
And I now yield to the Ranking Member, Ms. Brownley, for
any opening statement she may have.
OPENING STATEMENT OF RANKING MEMBER JULIA BROWNLEY
Ms. Brownley. Thank you, Mr. Chairman. And thank you for
calling this hearing today on VA staffing.
Section 301 of the Veterans Access, Care, and
Accountability Act, signed by the President last year, mandated
the VA shall submit a report assessing the staffing of each
medical facility of the Department. This hearing will
investigate this report and how the VA is doing in evaluating
the staffing needs around the country in respect to the care of
our veterans.
In its report, the VA cites the need for an additional
approximately 10,000 full-time employees to supplement the
approximate 180,000 employees that currently work in veterans'
healthcare. I am looking to find out from the VA how both
numbers were arrived at.
One issue is that last year Secretary McDonald quoted a
number of 28,000 positions needed to fully staff VA healthcare.
Now we are down to just over 10,000. The staffing report
concurs with the inspector general's report listing the top
five occupations that are most critical: medical officer,
nurse, physician assistant, physical therapist, and
psychologist.
One occupation not listed because it is not technically
healthcare-related is human resources. These are the people
that hire and fire and generally keep a facility fully staffed.
I am interested in hearing how the VHA will be streamlining its
hiring process and getting more people to work in a reasonable
timeframe to treat our veterans.
Veterans in my congressional district face barriers to
accessing care due to VA staffing issues. Ventura County is
home to over 47,000 veterans, and our local CBOC, which
provides primary care and mental health services, struggles
with staff retention. There are high turnover rates for
physicians and medical support staff.
The CBOC's primary-care team is down to just one physician,
two nurse practitioners, and one physician assistant. In
addition, our county veteran service officer is concerned that
veterans are not using important wraparound services because
there is no primary-care social worker on staff. Over the past
5 years, the number of veterans seeking mental healthcare at
the CBOC has doubled. And the VA has been working hard to meet
the growing demand, but we still seem to be in a place where we
are not fully staffed.
I know that staffing issues facing Ventura County are ones
that can be found across the VA system. I look forward to
hearing how VA is using the funding provided in the Choice Act
to increase the Department's workforce and high-demand
occupations so that the Nation's veterans have timely access to
the high-quality professional care that the VA is known for.
Thank you, Mr. Chairman, and I yield back the balance of my
time.
Dr. Benishek. Thank you, Brownley.
Joining on our first panel is Joan Clifford, immediate past
president of the Nurses Organization of Veterans Affairs; Dr.
Samuel Spagnolo, the president of the National Association of
Veterans Affairs Physicians and Dentists; Rubina DaSilva, the
president of the Veterans Affairs Physician Assistant
Association; Jeff Morris, the director of communications and
external affairs for the American Board of Physician
Specialties; and Dr. Nichol Salvo, member and employee of the
American Podiatric Medical Association.
Ms. Clifford, we will begin with you. Please proceed with
your testimony.
We allow everybody 5 minutes. So there should be a little
light there that when it goes red that means you are up.
Thanks.
STATEMENT OF JOAN CLIFFORD, MSM, R.N., FACHE
Ms. Clifford. Thank you.
Chairman Benishek, Ranking Member Brownley, and members of
the subcommittee, 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 testify on today's important
and timely subject, VA staffing.
As the Department of Veterans Affairs undergoes systemwide
reorganization, to include the many challenges of implementing
the Veterans Access, Choice, and Accountability Act, staffing
must be at the forefront of its evaluation.
I am Joan Clifford, deputy nurse executive at the VA Boston
Healthcare System, and I am here today as the immediate past
president of NOVA. NOVA is a professional organization for
registered nurses employed by VA. NOVA's focus is professional
issues.
NOVA is uniquely qualified to share its views on the
ability of VA to efficiently and effectively recruit, onboard,
and retain qualified healthcare professionals to treat our
veteran patients. As VA nurses, we are in the medical centers,
community-based outpatient clinics, and at the bedside every
day.
We have identified retention and recruitment of healthcare
professionals as a critically important issue in providing the
best care anywhere for our veterans, and we would like to offer
the following observations.
NOVA believes that the underlying issues reside in the lack
of a strong infrastructure for human resources, insufficient
nursing education opportunities, and the complex application
system, namely USAJOBS, that VHA uses for hiring staff.
VHA is facing a shortage of corporate experience and
insufficient HR staffing to support the multiple priorities
required for hiring healthcare professionals. The complex
hiring process, with systems that do not interface, lead to
extended waits for job offers. At times, this results in
candidates accepting non-VA jobs and puts VA back in the hunt
for qualified candidates.
Limited knowledge of direct hiring process for registered
nurses, resulting in unnecessary recruitment delays, and VA
processes and policies for obtaining recruitment and retaining
incentives contribute to delays in hiring personnel.
Reclassification and downgrades of some occupations, such as
surgical technicians, who are brought in at the GS-7 level and
have recently been downgraded to GS-5, are making it impossible
to competitively retain and recruit. A lack of knowledge on how
to maximize the locality pay law has resulted in inconsistent
application of the law, an obstacle to hiring and retention.
NOVA asks that the ceiling on nurse pay be increased to
prevent compression between the grades in order to remain
competitive.
Ensuring an infrastructure to sustain programs that produce
nursing graduates who honor and respect veterans' programs is
vital. The Office of Academic Affairs has supported a wonderful
R.N. residency program across some VAs, but funds are limited,
potentially impacting the recruitment of future hires who flock
to these programs.
The nurse practitioner residency program is currently a
pilot and will require continued funding to pay for resident
stipends and educational infrastructure. NOVA believes it is a
good investment, as hiring nurse practitioners will increase
access and enable additional services to veterans needing care
nationwide.
Ongoing support for tuition reimbursement and loan
forgiveness programs to help nurses defray the cost of
education if they work for VHA and support for VA nursing
academic partnerships is needed.
An area of concern is the use of advanced practice nurses,
which at this time is subject to State laws in which the
facility is located. VHA is advocating full practice authority,
which would result in all advanced-practice-registered nurses
employed by the VA to be able to function to the full extent of
their education, licensure, and training, regardless of the
State in which they live and work.
Legislation has been introduced, H.R. 1247, the Improving
Veterans Access to Care Act of 2015, which is the model already
practiced by the Department of Defense, Indian Health Service,
and Public Health Service systems. NOVA, together with other
national nursing organizations, are calling on Congress to
support this legislation, which would begin to address critical
needs within VA facilities by improving wait times and access
of care to all veterans.
VA employs over 90,000 nursing personnel, which is about a
third of its healthcare workforce. NOVA believes that there is
no greater time to have representatives from the Office of
Nursing Services at the table as VA reorganizes the way it
provides care and services to America's heroes.
Improvements and careful review of the process of
downgrades across VA, increased training and utilization of the
locality pay law, revising the cap on the R.N. pay schedule to
eliminate compression, as well as establishing a more user-
friendly application process and supporting human resource
offices across the Nation, will go a long way towards
correcting the challenges VA faces with staffing.
NOVA once again thanks you for this opportunity to testify,
and I would be pleased to answer any questions from the
committee.
[The prepared statement of Ms. Joan Clifford appears in the
Appendix]
Dr. Benishek. Thank you very much, Ms. Clifford.
Dr. Spagnolo, please go ahead.
STATEMENT OF SAMUEL V. SPAGNOLO, M.D.
Dr. Spagnolo. Mr. Chairman, we have submitted a written
testimony, and I would ask that you have that entered into the
record. And I will try to keep my few comments here fairly
brief.
Thank you for having us here, and thank the distinguished
members of the committee for having us here. We certainly
appreciate it.
I am here as a practicing physician, with more than four
decades with the VA. And I am here also as the president of the
National Association of VA Physicians and Dentists, usually
referred to as NAVAPD. I might add, too, that I am a veteran,
having served for 2 years of Active Duty in the United States
Public Health Service.
The National Association of VA Physicians and Dentists is a
501(c)(6) nonprofit organization that is dedicated to improving
the quality of patient care in the VA healthcare system and
ensuring the doctor-patient relationship is maintained and
strengthened. I appear today in pursuit of that purpose.
This year is NAVAPD's celebration of its 40th year. NAVAPD
believes that a key means of enhancing care of veterans is by
employing the best physicians and dentists. NAVAPD believes it
is essential for physicians to be involved in decisions
regarding delivery and quality of healthcare.
During my many years with the VA, I have witnessed
firsthand many changes in the VA--some good, some not so good.
I have had the opportunity to meet nearly all the Secretaries
of the VA over the last 40 years. I got to know several of them
very well, and a few I have seen as patients. I believe all of
these individuals have been good people and all of the best
intentions. I am sure Secretary McDonald, who I have also met
with, also has good intentions.
Notwithstanding the good intentions of these good people,
however, the role of the physician within the system as a
leader of medical care has greatly diminished over this same
period. Today, most physicians and dentists feel like their
opinions are neither helpful nor requested. At many centers,
physicians and dentists are no longer even considered
professionals but referred to simply as ``workers.'' These
observations come from our members--VA docs and dentists, men
and women who want to help improve veterans' care.
In the late 1960s and 1970s, nearly all VA medical centers
were led by directors who were physicians. Today, very few
medical centers have physician directors. The position now
called the VA Under Secretary of Health was known as the chief
medical director. At that time, there was a direct line from
the chief of staff at the medical center to the chief medical
director. Issues of delivery and quality of medical care were
raised and addressed by medical professionals. Today, chiefs of
staff report to a clinical specialist at the VISN centers.
In more recent times, there has also been a strong movement
to eliminate the need even to have a physician in the role of
Under Secretary of Health. I ask, would it be wise or even
possible to run the Defense Department without generals and
admirals in leadership positions? We are not saying there is no
role for nonphysicians in the administration of hospitals or
medical care. We are saying, however, that medical judgment
should be based on years of education and patient care.
Physicians are being loaded with additional duties more
appropriate for nonphysicians, such as typing, filing letters,
followup calls, patient reception, and preparation. Similarly,
it is not cost-saving nor efficient to have physicians
routinely escort patients from waiting rooms to exam rooms and
having them help the patients get undressed.
There is a growing trend to add nonphysicians, and there is
a growing concern that a veteran may never be seen or treated
by a physician while in the VA healthcare system. Veterans are
seen by non-M.D. doctors without ever realizing they have not
seen a medical doctor. We believe this is dangerous for
patients and their families, and it may also raise some ethical
issues.
The VA is currently considering a change in its nursing
handbook. Under the proposed handbook, there will no longer be
any physician oversight for the process of sedation and
providing operating room anesthesia by certified registered
nurse anesthetist. The proposed change provides no guarantee
this will provide safer patient care. Additionally, LPNs with
little or no psychiatric experience are taking the place of
psychiatrists during intake counseling and assessments in some
psychiatric departments.
Taking care of patients and providing excellent care has a
lot to do with providing the basics and using a lot of common
sense. For example, when patients are asked what is important
to them, you will hear simple, straightforward, commonsense
questions, such as: Will I be admitted quickly? Is the room
clean? Is there a bathroom in the room? Does the call button
work, and does someone answer and arrive quickly when I need
them? Does everyone speak so I can understand them? If I need
help to eat, will there be somebody there to help me? Do my
doctors and nurses spend time explaining things so that I can
understand what is happening? Unfortunately, patient surveys
indicate that none of the above questions are being answered
very well in the VA.
Although the crisis last year in VA did focus on access to
care, this is but one small piece of the total package. Getting
timely initial access is of little value if it takes months to
get your hip replaced or have a lung cancer removed or a
colonoscopy screening because there may not be sufficient
physicians or adequate access to the operating room. Timely
access must be assured throughout the course of care, not just
on the initial visit.
VA is referred to as a healthcare system. At best, it is a
collective of hospitals and other medical facilities operating
under a common umbrella. The operational standards at every
facility appear to be different. There must be unification and
simplification of process across the organization to achieve an
order of efficiency and common outcomes. When you have seen one
VA, you have only seen one VA.
In this regard, we have seen no recent operational
structural changes that would increase the efficiency of
physicians and dentists in the VA. Changes announced by the
current Secretary are not being consistently implemented in
local facilities, perhaps because the facility leaders have not
understood that these changes are mandatory----
Dr. Benishek. Doctor, you will have to clean up your time
here.
Dr. Spagnolo. I am--one sentence left.
Dr. Benishek. Okay. Good.
Dr. Spagnolo. Hearings like this are important and helpful,
and the VA appreciates the--NAVAPD appreciates the opportunity
to be here today. We want to help fix the medical care problem.
The unfortunate truth, however: It is far easier to throw money
at the situation than it is to fix it.
Thank you, Mr. Chairman.
[The prepared statement of Dr. Spagnolo appears in the
Appendix]
Dr. Benishek. Thank you, Doctor.
Mr. Morris, you have 5 minutes to come across with your
testimony.
STATEMENT OF JEFF L. MORRIS, J.D.
Mr. Morris. Chairman Benishek, Ranking Minority Member
Brownley, and distinguished members of the Health Subcommittee,
the American Board of Physician Specialities thanks you for the
examining the issue of overcoming barriers to more efficient
and effective VA staffing.
Veterans should never be shortchanged in their medical
care. Recruiting qualified and highly skilled physicians to
work within the VA health system is needed now more than ever.
What many do not know is that physician politics, along with
existing discriminatory and monopolization practices of the
American Board of Medical Specialties, are keeping excellent
physicians out. What is indefensible is that they are not
denied because of their training, education, or experience.
These highly skilled physicians are being denied employment
solely based on their choice in board certification.
Dr. Robert M. Weinacker is a prime example of this very
discrimination going on within the Administration. Dr.
Weinacker, a veteran himself, was a Green Beret and former
member of Special Forces. He was even handpicked as battalion
surgeon to lead the medical treatment of 400 of our Special
Forces. He wanted to work at the VA. He applied for seven
positions and was never even called back for an interview.
This was not due to his training. Dr. Weinacker, a graduate
of the University of Alabama Medical School, is residency-
trained in radiation oncology and is a fellow of the American
Academy of Radiology. In addition to his medical profession,
Dr. Weinacker is also an attorney in hospital administration,
with a focus on waste, fraud, and abuse.
The only barrier that prevented Dr. Weinacker from working
at a VA was his choice in certification. He chose--each
position required ABMS certification only. Dr. Weinacker chose
ABPS, and, because of that choice, he is consistently denied
the opportunity to take care of his fellow veterans.
We are here to ask the VA to cease their discrimination of
ABPS physicians such as Dr. Weinacker. Behind this
discrimination is the fact that most people do not understand
what board certification is. Board certification is a choice
and an indicator that a practitioner has demonstrated their
mastery of the core body of knowledge and skills in their
chosen specialty.
Currently, there are three recognized multispecialty
certifying bodies: the American Board of Medical Specialities,
the American Osteopathic Association, and the American Board of
Physician Specialties. ABMS, the largest of the 3, is made up
of 24 individual specialty bodies, making many believe that
they are all different entities. This structure has hidden the
monopoly that ABMS has been establishing, making many believe
they are the only one.
ABMS is not the only higher standard board. There are
others that meet or exceed their standards. In fact, ABPS is
the only one of the three to have received an independent
affirmation of the high standards of its exams through an
exhaustive review process performed by Castle Worldwide.
Since 1994, ABPS has approached the Department regarding
these discriminatory staffing issues creating barriers to
hiring skilled physicians. Each time, the Administration would
protect the ongoing monopoly and respond that they had no plans
to recognize anyone else.
In 2011, ABPS returned to the Administration to stop the
discrimination and further explain that we were a part of the
current standard of certification. They again refused to see
the issues.
All these discussions were led by former Under Secretaries
of Health Drs. Petzel and Jesse, along with Dr. Karen Sanders--
all board-certified by the very same organization keeping ABPS
and other highly skilled physicians out.
What is most confusing is that, under the GI bill, ABPS has
been reviewed and approved by the U.S. Department of Veterans
Affairs. Yet they stated to us that it does not mean they have
to accept it. The VA reimburses for ABPS board certification
but will not recognize it for hiring or promotion.
The Administration also stated to us that board
certification is not a requirement, that it is left to the
discretion of the local VA. However, this has not been the
case. According to USAJOBS, there are over 1,000 open physician
positions. Most blatantly discriminate by requiring ABMS/AOA
only, limiting the ability to fill much-needed positions.
Only a few hospitals recognize ABPS and have hired them to
fill their staffing needs. The Kansas City VA is a good example
of this, providing a higher level of care. Some also have hired
ABPS physicians, but ABMS continuously creates a hostile work
environment and openly discriminates against them. Many of
those physicians are not here today because they feared
retribution or loss of their jobs.
ABPA wishes to contribute to solutions to ensure that
veterans receive the highest quality of care. A directive from
the Office of the Secretary of the VA needs to be in place that
creates antidiscrimination policy, that clearly defines board
certification and goes beyond just the acceptance of ABMS/AOA.
Job listings should no longer allow for one specific board over
another.
We also ask that a quarterly reporting structure be
developed. Whereas VA healthcare institutions report on
applications received, the denial and hiring of physicians and
all applicant boards be identified, having identified
individuals accountable for this oversight--all done in a
similar manner as corporations are required to identify and
ensure minority hiring. This will allow for a transparent
credentialing process, and local VA medical centers will be
held accountable.
Thank you again for this opportunity. The ABPS looks
forward to working with you to improve hiring practices and end
the discrimination. Most importantly, our veterans' health,
safety, and care must be placed before physician politics and
the egos of a few. It is what they deserve.
[The prepared statement of Mr. Jeff Morris appears in the
Appendix]
Dr. Benishek. Thank you, Mr. Morris.
Ms. DaSilva, you are up next.
STATEMENT OF RUBINA DaSILVA, PA-C
Ms. DaSilva. Chairman Benishek, Ranking Member Brownley,
and other members of the Health Veterans' Affairs Subcommittee,
on behalf of the entire Veterans Affairs Physician Assistant
Association, we really appreciate the invitation to provide
this testimony before you today.
The PA profession has a very special and unique
relationship with veterans. The PA profession came into
existence in the 1960s due to the shortage of primary-care
physicians in the United States. The first graduates of the
Duke University program in 1967 were former Navy hospital
corpsmen.
The VA was the first employer of the PAs and, to this day,
is still the single largest employer of PAs in the country.
Currently, there are 2,020 PAs working in the VA system. These
PAs provide cost-effective, high-quality healthcare, working in
hundreds of VA medical centers and outpatient clinics. In the
VA system, about a quarter of all primary-care patients are
treated and seen by a PA. Approximately 32 percent of those PAs
are veterans, including myself. I am a former Navy hospital
corpsman.
The OIG report of January 2015 conducted a determination of
the VA occupations with the largest staffing shortages, as
required by the Veterans Choice Act. OIG determined that PAs
were the third critical occupation on the list compared to all
others.
According to the National Workforce Succession Planning of
2015, next year, in 2016, 37 percent of PAs are eligible to
retire. This workforce loss will result in approximately a loss
of 1.15 million veteran eligible patient care appointments. In
2014, PAs had the highest total loss rate of 10 percent, more
than any of the other top 10 occupations deemed difficult to
recruit and retain.
Utilizing the VA provisions of the Veterans Choice Act of
2015, the VA reports no current plans for recruiting for new PA
positions and for retaining an optimal PA workforce. They are
setting goals to hire only physicians and nurses, as they
interpret the law, and so not including the PA workforce.
Some facilities are not posting for PAs at all under the
Veterans Choice Act. Of the total postings nationally for PAs,
there are only 83. This method effectively eliminates 50
percent of eligible applicants. And when medical centers or
CBOCs do not post for PAs, the centers send a message that PAs
and PA veterans should not and cannot apply, even though
military PAs often have higher levels of experience from
frontline battlefield care.
The discrepancy in salary, benefits, and education debt-
reduction programs between the civilian sector and the VA
continues to be a recruiting and retention barrier.
There are three types of providers within the VA that
provide direct patient care: physicians, physician assistants,
and nurse practitioners. Physicians are mandated a yearly
market pay survey. Nurse practitioners, by virtue of being a
nurse, are mandated under the yearly R.N. locality pay scale.
PAs fall under a special salary rate. However, this is not
mandated yearly. Some facilities have not performed a special
salary survey for 11 years.
Reporting in the results of the VISN 2014 Workforce
Succession Plan, 88 VA main facilities report the reason that
their VISN cannot hire PAs is because they cannot compete with
the private-sector pay.
The Secretary can convert physician assistants to covered
positions and pay them pursuant to current public law. However,
the VA has refused to pursue these steps to solve their current
retention problems for PAs. The recommendation is Congress
should legislate a mandate that the VA Under Secretary for
Health include PAs in the nurse locality pay system under title
38.
For the education debt-reduction program, VAPA 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 2013, only 44
physician assistants have received $319,000 in scholarships,
compared to 705 registered nurses seeking to become nurse
practitioners receiving scholarship awards totaling over $11
million in support of NPs and NP programs.
The recommendation is that VAs must advertise in all PA
vacancy announcements so prospective applicants are aware of
the education debt reduction--loan forgiveness. Move the
program application process for accountability nationally since
this is not a facility-funded but a VA-funded program.
Next is the Independent Care Technician, the ICT, Program,
also known as the Grow Your Own program. To assist returning
OIF/OEF returning veterans, to include targeted scholarships,
Grow Your Own mandates the VA shall appoint a PA ICT program
director to coordinate the educational assistance necessary to
be a liaison with PA university programs so these corpsmen and
medics can follow the footsteps and become PAs.
For recruitment, move all direct patient care positions to
the National Recruiter/Workforce Office.
In conclusion, Chairman Benishek, Ranking Member Brownley,
and other members, as you strive to assure that veterans
receive timely access to quality healthcare and demand more
accountability into the VA healthcare system, we strongly urge
the full committee to review the report and critical role of
the PA profession and ensure the VA take immediate steps to
address the current problems on a national level and not leave
it to the VISN and local facilities to address the problem, as
the OIG report shows the PA profession continuously moving up
the list on critical occupations. The PA profession was borne
from the military, and we need to continue that special
relationship.
On behalf of the entire membership of the Veterans Affairs
Physician Assistant Association, I really appreciate this
opportunity to testify here before you today and ask for your
help in supporting the Nation's veterans.
[The statement of Ms. Rubina DaSilva appears in the
Appendix]
Dr. Benishek. Thank you, Ms. DaSilva.
Ms. DaSilva. Yes, sir.
Dr. Benishek. Dr. Salvo, you are up.
STATEMENT OF NICHOL L. SALVO, DPM
Dr. Salvo. Chairman Benishek, Ranking Member Brownley, and
members of the subcommittee, I welcome and appreciate the
opportunity to testify on behalf of the American Podiatric
Medical Association.
I commend this subcommittee for its focus to assist and
direct the Veterans Administration to effectively and
efficiently recruit and retain qualified medical professionals
and improve access to quality healthcare in the VA.
I am Dr. Nichol Salvo, member and director of young
physicians at APMA. I am also a practicing podiatrist,
maintaining a without-compensation VA appointment. I am before
you today representing APMA and the podiatric medical
profession. While I do not represent VA, I do bring with me
firsthand experience and knowledge of hiring practices within
VA and knowledge of the widespread disparity between podiatric
physicians and other VA physicians.
Mr. Chairman, when the VA's qualification standards for
podiatry were adopted in 1976, I was not yet born. Podiatry
starkly contrasted with that of physician providers of the time
and is a far cry from podiatric medicine as it is today.
Unlike 39 years ago, current podiatric medical school
curriculum is vastly expanded in medicine, surgery, and patient
encounters. Back then, residencies were few and were not
required. Today, there are mandated standardized comprehensive
3-year medicine and surgery residencies to satisfy all of our
graduates, with 77 positions housed within the VA, each
requiring completion of a broad curriculum equitable to medical
and osteopathic residency training.
Today's podiatrists are appointed as medical staff at the
vast majority of hospitals, and many serve in leadership roles
within those institutions. Many of my colleagues have full
admitting privileges and are responsible for emergency and
trauma calls.
The competency, skill, and scope of today's podiatric
physicians has certainly grown from the podiatrists that
practiced before I was born. Because of this, CMS recognizes
today's podiatrists as physicians, and TRICARE recognizes us as
licensed independent practitioners. That is today's podiatrist.
We must also understand today's veteran. Veteran patients,
often plagued by socioeconomic and psychosocial issues, are
ailing, have more comorbid disease, and are of
disproportionately poor health status compared to their
nonveteran counterparts. These patients increase the burden of
diabetic foot ulcers and amputations, and, as documented in my
written testimony, almost 2 million veterans are at risk of
amputation with underlying diabetes, sensory neuropathy, and
nonhealing foot ulcers.
This is my patient population. The veteran population is
far more complex to treat than patients in the private sector
as a whole. One of our major missions is amputation prevention
and limb salvage, which provides a cost savings to VA and an
integral role of the veteran quality of life.
As part of the interdisciplinary team, podiatrists
independently manage patients within our respective State scope
of practice, and we assume the same clinical, surgical, and
administrative responsibilities as any other unsupervised
medical and surgical specialty.
Despite this equality in work responsibility, there exists
a marked disparity in pay and recognition of podiatrists as
physicians in the VA. The majority of new podiatric hires have
minimal experience and lack board certification. The majority
of these new hires will separate from the VA within 5 years.
I am speaking to you from personal experience, as I am one
of the majority. I entered the VA without board certification,
with less than 5 years of experience. I gained my experience,
earned my board certification, and then separated from the VA
to take a leadership position with my parent organization.
While I will forever remain loyal to the veterans, which is
why I still voluntarily treat patients in my local facility
without compensation, I testify to the profound disparity.
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 10 years, and these proposals
have been denied every single year, as were several requests
for an internal fix, despite written letters of support from
the former Under Secretary of Health Robert Petzel, M.D.
Five years ago, APMA leadership made this issue a top
priority. Since then, we have alerted the VA to our knowledge
of this issue, and, in response, former Under Secretary Petzel
created a working group with whom we have participated in
several meetings and from whom we recently received
acknowledgment of the need of a legislative solution to address
this issue.
In closing, I would like to state that oftentimes we find
that the simplest solution is the best. I come before this
committee today to respectfully request that Congress help the
VA and its patients by passing legislation to recognize
podiatric physicians and surgeons in the physician and dentist
pay band.
We believe that simply changing the law to recognize
podiatry both for the advancements that we have made to our
profession and for the contributions that we make in the
delivery of lower-extremity care for our veteran population
will resolve recruitment and retention problems for the VA and
our veterans.
Mr. Chairman and members of the subcommittee, thank you
again for this opportunity. This concludes my testimony, and I
am available for questions.
[The statement of Dr. Nichol Salvo appears in the Appendix]
Dr. Benishek. Thank you, Dr. Salvo. I appreciate it.
I will yield myself 5 minutes for questions.
Boy, there are a lot of questions I would like to get
answered here today from many of you. I think I will start with
Ms. Clifford, though, because I think you brought up something
that is pertinent here.
How long does the average hiring process take? How long is
that time? And talk a bit more about the difficulty in getting
people because they take a job somewhere else while the process
is ongoing.
Ms. Clifford. Right. So it is pretty variable, and it can
go anywhere from 2 to 6 months or maybe more in some places.
It is a very complex process. First, at most places, it
will have to go through a resource committee for approval,
which usually is the quickest part of the process. It then has
to get posted on USAJOBS, so it has to be put in the proper
format to be posted on that. And then we wait and get the
certification of who has applied for that position. And then
they have to go through all of these other processes we have,
such as e-QIP, which is the background check. We have the----
Dr. Benishek. In other words, like, 2 to 6 months----
Ms. Clifford. Yes.
Dr. Benishek [continuing]. In order to get hired. And so,
like, the least amount of time is, like, 2 months.
Ms. Clifford. I think 2 months would be considered a good
hire--a quick hire.
Dr. Benishek. Because I know that in the private sector it
doesn't take--if you apply for a job, it doesn't take 2 months.
They get hired in the private sector at the local hospital--I
mean, in my experience. Do you have any experience with numbers
in the private sector?
Ms. Clifford. That is correct. I don't have any numbers,
but I do know that that is what we hear from some of our
candidates. And it will come to the point where they will say,
I have another job offer, you know, how quickly can you tell me
whether or not I can have it. Because they probably haven't
even given notice to their other job, so it is another month
after we even make the job offer to get them in the door.
Dr. Benishek. Dr. Spagnolo, can you comment on the same
question as far as the physician side of things? I know that,
there is a lot of trouble with the qualifications or making
sure that the person's background is right and on getting that
right. But how does that process work in the VA, from your
experience?
Dr. Spagnolo. I would echo what you just heard. It takes
sometimes up to a year to recruit a physician. I have heard
them taking even longer.
I also run the respiratory care department, and it is
usually a year before we can hire a therapist, to get through
all the processes and finally get them in. Working with H.R. is
near impossible.
Dr. Benishek. So this is all done through the H.R.
department then? I mean, the physician hires, as well?
Dr. Spagnolo. Well, you know, there is more than just the
H.R. You have to get it approved by different committees and
chairmen and hospital directors, and then it goes back and
forth. It just takes forever.
Dr. Benishek. Now, Dr. Salvo, you mentioned the podiatrist
problem in the VA. At the VA that I worked at, the podiatrist
was one of the busiest providers in the surgery clinic. I mean,
they had a hard time keeping the podiatrists there long enough
to do all the work you had to do.
What is the difference in the payment? Are they not paid as
physicians then? Can you explain that to me a little bit more?
Dr. Salvo. Podiatry is on a different pay scale.
Unofficially, I am aware that the pay scale ranges anywhere
from $60,000 to a $100,000 less from other VA medical and
surgical specialties, depending on what the specialty is.
Dr. Benishek. Well, that would sort of explain why it is
difficult to recruit.
Ms. DaSilva, do you have anything to add on that, on that
recruitment and difficulty-in-hiring question?
Ms. DaSilva. I would agree with--it does take a long time.
It takes about 6 weeks in the private sector, max, whereas in
the VA system it can take up to 6 months.
Dr. Benishek. Dr. Spagnolo, could you expand a little bit
about my concern when I worked the VA was the fact that, the
doctors weren't involved with making the decisions in
departments that actually involved how the patient care is
delivered. They were sort of told what to do by the
administration and then left to do that.
Can you expand on that thought? Do you agree with my
thinking there? And what should be done about it?
Dr. Spagnolo. Well, yes, we need to empower the physicians
in the facilities. I think if you took people, in every VA
facility, you took a dozen people in the facility who knew
really what was going on, you could find out very quickly what
was working and what wasn't working. You need to empower some
of the nurses, you need to empower the physicians, get some
real input on how to become more efficient and how to provide
better care. I think that could be done very quickly.
Dr. Benishek. Thank you.
I am out of time, and I will yield to Ms. Brownley.
Ms. Brownley. Thank you, Mr. Chairman.
I know that the Secretary of the VA is really trying to
make transformation at the VA. And I have heard him and others
from the VA testify that we need to shift the VA from a rule-
based organization to a principle-based organization.
And it sounds to me, based on the longevity of hiring
people within the VA, it is the rules that are--because there
are so many, is what slows the whole process down, that we
would be better off following the practices of private industry
in terms of hiring.
Is that a fair assessment for nurses?
Ms. Clifford. I would say so. There is a lot--it is very
complex, lots of steps in the process from the human resource
side, and that is what causes a lot of the delay.
Ms. Brownley. So, for the nurses, unlike the physicians,
the problems are predominantly within the human resources
department and their rules. Hiring doctors, you go through
human resources but have to go outside of human resources, as
well?
Yes, yes, yes, and yes?
Ms. Clifford. I am not sure I understand the question about
going outside.
Ms. Brownley. So Dr. Spagnolo testified for longevity, in
terms of hiring physicians, that it is within the human
resources department but they also have to go outside of the
human resources and, I presume, be interviewed by other
physicians or other departments. And I am just wondering, for
nurses, is the whole hiring process within the human resources
department?
Ms. Clifford. Well, the nurse managers or the supervisors
make the decision of who they want to hire, and then the
technical parts are all done by human resources.
Ms. Brownley. And the same for physicians?
Dr. Spagnolo. I can't tell you how many human resource
officers I have seen go by in 40 years. But every new director
that came to our facility in the last 40 years has said, ``My
number-one priority is to fix H.R.'' It has never been fixed.
Ms. Brownley. Mr. Spagnolo, your testimony was shocking,
when you said sometimes veterans have medical appointments for
care and leave not knowing that they did not see a physician or
medical expert of any kind. That is pretty shocking testimony
to me.
And then when I hear some of the obstacles around physician
assistants and the shortage there, I am not sure what to say,
except we have a lot of improvements to make.
But, I mean, do you think that that is a common occurrence,
where a veteran comes for an appointment for medical services
and never sees a physician?
Dr. Spagnolo. Was the question do I think it is common?
Ms. Brownley. Yes.
Dr. Spagnolo. Yes, I think it is quite common.
Ms. Brownley. And how do you think--you also said in your
testimony that physicians are doing nonphysician care, like
typing and filing and followup calls and helping patients
change their clothes and patient reception, et cetera.
How did that happen? How did those responsibilities become
the responsibilities of the physician? Is it just because of
the shortage of people in the operation, or are these specific
responsibilities of a physician?
Dr. Spagnolo. I don't know specifically how that has
occurred over the years, but I can tell you that when I was a
chief of staff a number of years ago, I used to say to our
hospital director when he would come in and yell at me and say
our docs aren't seeing enough patients--and I keep telling him
that the reason they can't see patients is there is nobody in
the clinic to assist them to see the patient.
They have one examining room. They have to go get the
patient. They have to help get the patient undressed. They have
to see the patient. Then they have to write a note, usually on
the computer nowadays. And they have to help the patient get
dressed, and then they have to escort the patient out of the
room.
How many times in a day can you do that when you have no
other help? You have nobody to help input data into the
computer. You have no one to help you request drugs for
patients into the computer. You are basically doing the
physician, the secretary, the receptionist.
It is very difficult to be efficient--not that the
physicians don't want to be efficient. They would love to be
efficient, but the system doesn't permit it. And when you talk
to the administrators, they just glaze over. It gets the
physicians extraordinarily frustrated. They would love to see
more patients. Everybody would love to see more patients.
Ms. Brownley. Thank you, Doctor.
My time is up, and I yield back.
Dr. Benishek. Dr. Roe, you are recognized for 5 minutes.
Dr. Roe. Thank you, Mr. Chairman.
And, Dr. Salvo, you really threw me off when I realized I
have been a doctor longer than you have been alive.
Dr. Spagnolo, I suspect you had the same sort of angst as I
did.
A couple of things I just want to go over very quickly. I
have to run to the airport and catch an airplane. But, number
one, I think you very clearly pointed out the loss of
professionalism that is occurring.
In my practice, I had an assistant, I had a nurse with me,
I had three examining rooms. I could really see a lot of
patients very efficiently and very well. You cannot see
patients efficiently in that circumstance. It is impossible.
You can't make you more productive when you have six jobs. And
I think that very loss of professionalism has occurred.
I think another thing that has occurred in the VA is that
we have fewer M.D. providers as hospital administrators. If you
have been in the trenches working, you understand exactly how
that clinic works. I understand exactly how your clinic works
or doesn't work. So I think that is one of the issues we have
to deal with.
And I think another question I have right quickly is, what
is the retention problem? When you hire people, there is this
huge turnover, both in nursing and on the medical side. What do
you all see as that? Why is that? Is it the working conditions?
The pay? I mean, there are a lot of things you have gone over,
but why is that?
Dr. Spagnolo. I will take a stab, and then it is yours.
Ms. Clifford. Okay.
Dr. Spagnolo. They come to work with great enthusiasm. Good
people, they get put into these situations where, after 6
months or a year, they just are frustrated, depressed, tired,
nobody listens, and they leave. So your turnover rates, I don't
know what they are nationally, but I know that in primary care
some places have turnover rates of 100 percent every year.
It is frustration. Primarily frustration, I would say.
Dr. Roe. And--excuse me. Go ahead, Ms. Clifford.
Ms. Clifford. So I would say it is, again, dependent on
different facilities. To your point that people all come in
with the best of intentions, but if you happen to be in an area
that has a difficult time recruiting, then they are kind of
always behind the eight ball. They are required to do a lot of
overtime, or they are having lots of shift changes, and so
people get frustrated and burnt out and leave. But in
facilities that are able to maintain that, people stay because
they stay for the mission of the VA.
Dr. Roe. Two other quick questions.
One is, from Mr. Morris' standpoint, is there a barrier? If
you have a different--I am certified by the American Board, but
are there barriers out there for other board certifications
that you see that help reduce staffing? Is that a real issue
that he brought up or not?
And I guess, Dr. Spagnolo, you can answer it, or Mr. Morris
can answer it, either one.
And the second----
Dr. Spagnolo. I think within certain----
Dr. Roe. Let me throw the second one out so you can just
answer it.
You know, the Veterans Choice Act, which we spent a lot of
time on and getting passed, provided $5 billion to increase
staffing for the VA. Is that happening? Is that money being
used that way?
Those are my two questions.
Dr. Spagnolo. If your question is, on the Veterans Choice
Act, whether they are utilizing it, is that----
Dr. Roe. Yes, sir.
Dr. Spagnolo. I don't know how much they are utilizing it,
to be honest with you. I don't know if the--I know that we have
tried to have a few people go somewhere else. One had an
artificial heart. And it was like a nightmare to get that done,
because the facility that they were to go to had no experience
with that.
I can't tell you how it is across the VA. From what I hear,
it is not very efficient. So if it is going to work, it has to
be efficient.
I would like to see within the VA more efficiencies and
getting these procedures done more quickly. I mean, some
physicians have no--their access to the operating room is 1 or
2 days a week.
Dr. Roe. Okay.
That second--you know, with staffing less physicians, as
Mr. Morris pointed out, is being boarded by somebody other than
what I am boarded by, is that a barrier to hiring people?
Dr. Spagnolo. Yes, I think it is a barrier.
Dr. Roe. Is it a legitimate barrier, or is it----
Dr. Spagnolo. I think it is a legitimate barrier in some
situations.
Dr. Roe. Okay.
Any other comments on that? Have any of you--Dr. Salvo,
have you seen that?
Dr. Salvo. I am not--in my capacity as a WOC (Without
Compensation) appointment within the VA, I have had to deal
almost nothing with the Veterans Choice Act personally. That is
purely administrative by other departments.
Dr. Roe. Yes.
Ms. DaSilva.
Ms. DaSilva. Sir, I do want to say with the Veterans Choice
Act, it has been interpreted to not include physician
assistants by some facilities. So if you wanted to talk about
increasing recruitment, if the jobs aren't even posted and
physician assistants aren't even able to apply for those jobs,
that is not going to increase access for care for veterans.
Dr. Roe. Well, Just as I head out the door, it isn't really
hard to figure out your needs when you just call the people
scheduling appointments and find out you have a 6-month wait.
It isn't rocket science. Look, I have been doing it for four
decades, and you find out, and all of you there know, if you
have a long waiting list for patients to come in, you need to
hire people to take care of those waiting lists or make your
shop more efficient. It is not complicated. I mean, I did it
for years.
And, I mean, the way I learned out if I needed anybody is I
would go to church and somebody would say, I can't get an
appointment with you for 6 months. I would figure, hey, maybe
we better hire another practitioner, and we did. And that is
what I see there.
So my time has expired, Mr. Chairman. Thank you for
indulging me.
Dr. Benishek. Thank you, Mr. Roe.
Mr. O'Rourke. You are recognized for 5 minutes.
Mr. O'Rourke. Thank you, Mr. Chairman.
I want to thank everyone on the panel for being here. And
your commitment to improving the VA and serving our veterans
gives me an opportunity to remember and thank those who serve
the veterans in El Paso, Texas. That is the district I have the
honor of serving.
And, Dr. Salvo, your story of continuing to treat veterans
without compensation reminds me of people that I have met at
the VA who are providers there who could be working in the
private sector at much greater pay and probably much less
frustration and yet choose to work at the VA because they want
to serve veterans, and they do a wonderful job.
And I hear that from the veterans that they treat and serve
directly, you know, that it is really hard to get in, and there
is a lot of frustration with the bureaucracy, but once you are
seen by a provider, typically, the experience is excellent. And
I think that is something that I have heard my colleagues on
the committee share, as well.
Two things stick out to me, in terms of the larger picture.
One is--we heard the Deputy Secretary say this day before
yesterday, Sloan Gibson--that there are 28,000 unfilled
positions at the VA today. Just the hiring challenge there is
just monumental, staggering. I don't know how you get over it.
And it hasn't improved in a year.
And the other is that wait times also have not improved in
a year. You know, $15 billion or $16 billion authorized and
appropriated this summer; program went live in November. Dr.
Spagnolo, you said you are not sure if you have seen any
significant change in access or treatment as a result of that.
We know from a hearing earlier this week that we thought that
$10 billion of that were going to be obligated sometime in the
early part of fiscal year 2016, which could take you to maybe
December or January, you know, in the next 6 months, and only
$500 million has been obligated.
So you all have each offered important suggestions to
improve the delivery of care and the hiring and the speed at
which we bring people on board. And I am really glad that Dr.
Lynch is here to listen to all this, and I know that he is
taking note of this and will incorporate these, I hope, into
the operations at the VA. But I am also looking for some kind
of big breakthrough in what we are doing.
I don't know that, with these 28,000 outstanding hires,
with wait times that haven't improved despite the notoriety
around the crisis in Phoenix and all the attention that we have
spent and the new legislation that we thought was going to fix
it, I don't know that this model works, nor should we expect it
to work.
And, you know, one of you said it is not going to be a
matter of resources. We can't throw more money at this and just
expect it--we can hire people more quickly. You know, I heard
these same stories. We had a psychologist who was hired from
Georgia, recruited by the VA in El Paso. And he said, you know,
sure, I would like to do this job, sign me up, and it took 3
months to bring him on. They recruited him, and it took 3
months. And in that time he said, you know, there were several
other offers, and I thought about taking them, but I wanted to
serve in an underserved area.
So I realize I have chewed up most of the time I had, but I
want to offer the last minute and a half to anyone who might
have a big breakthrough idea on how we change what is obviously
a system that just doesn't work.
Ms. Clifford, it looks like you might have one.
Ms. Clifford. Well, I don't know if it is a breakthrough
idea, but if we don't address the human resource piece of it--
and from that, I just want to go on record as saying it is not
the staff that are doing the work there. They are killing
themselves trying to help us get these people in. But the task
ahead of them is just so overwhelming that--I don't know what
their retention rates are, but I would think they are not very
good because they turn over very quickly. Because it takes a
lot of time to get them trained, and so they don't stay long
enough to get trained. And they go to other jobs, either in
other parts of the government or out of human resources
altogether.
So if we kind of don't address that area--because they are
our bread and butter of getting people in.
Mr. O'Rourke. And that is an open question from me to each
of you. And I am sure my colleagues on the committee would all
be interested in hearing your answer. So we are not going to
have time to get that from each of you today, but know that I
think, you know, speak for myself, very interested in a
different way forward.
I think more of the same we have seen from the last year,
despite, you know, what I think is tremendous leadership on the
part of the VA and the new Secretary, it is just not working.
And the people who are delivering that care on the front lines
are suffering, and what is even more important, the people that
they serve are suffering. And we have to have a big, bold path
forward to fix this.
So, with that, I yield back to the chair.
Dr. Benishek. Thank you, Mr. O'Rourke.
Mr. Coffman, you are recognized for 5 minutes.
Mr. Coffman. Thank you, Mr. Chairman.
We get scope-of-practice questions here in the Congress
relative to the Veterans Administration. I think a lot of these
issues have been resolved down at the State level before State
legislatures. And I have been on both sides of it as a State
legislator, where I think they are better qualified at the
State level to make those decisions. They can have hearings;
you know, they know that the docs, the providers within their
communities.
And so I guess my question to you is, clearly, you know,
people that--well, my question to you is, what do you think
about devolving the scope-of-practice issues down to reflect
whatever the standards are within the given States that these
VA facilities are in, number one?
And, obviously, we are going to make sure that the
providers are properly credentialed or trained to be able to
perform those duties within the scope of practice. So devolve
it down to the State level, reflect State regulations wherever
these VA facilities are, as opposed to us relitigating these
issues at the Federal level.
Would anybody like to comment on that?
Ms. Clifford. Well, I can speak to it from the advanced
practice realm. And the issue becomes--we care for patients
across States, and so different States have different nurse
practice acts which allow the nurse practitioners to do
different things at different levels and how much independent
practice they can have.
So, in VA Boston, for example, we are a referral center, so
we are patients from Maine and New Hampshire, and yet the nurse
practitioners in some States are able to do things and are not
able to in other States. So it makes it--it is hard for us to
give equitable care across all of our veterans when we have
different practices across.
Mr. Coffman. Anybody else?
Dr. Spagnolo. I am not sure I could respond to that because
I have never really thought of that as an answer, but probably
have to probably look at that a little bit more and see where
that would take us. But it may be a possibility; I don't know.
But I would like to get back to you on that.
Mr. Coffman. As an example, the issue between
anesthesiologists and nurse anesthetists has been settled
across this country in different States. And now both sides
want us to relitigate it here at the Federal level where I
would just as soon to defer to those State legislatures who
have made those decisions. So that would be an example.
Dr. Spagnolo. I would have to look at that across State
lines. I don't have a good answer for you on that whole issue.
But I will get back to you on that.
Mr. Coffman. Okay.
Thank you, Mr. Chairman. I yield back.
Dr. Benishek. Thank you, Mr. Coffman.
Mr. Takano is next.
Mr. Takano. Thank you, Mr. Chairman. Thank you.
Ms. Clifford, thank you for your testimony today about the
vital that role nurses play in the VA and how we can better
attract and retain nurses to care for our veterans.
You mentioned something about streamlining the hiring
process and improving education resources for nurses, but I am
wondering about your thoughts about giving nurses improved
rights to raise grievances about staffing levels and how that
can improve the workplace, empower nurses, and encourage them
to continue serving our veterans.
In a statement submitted for the record, the AFGE mentions
that through a loophole nurses and other VA healthcare
providers are denied full collective bargaining rights that
other Federal employees have. The AFGE supports a bill that I
have introduced, H.R. 2193, the VA Employee Fairness Act, to
expand providers' ability to negotiate to improve staffing
levels and in turn the care our veterans receive.
Mr. Takano. Do you think we need to pay attention to the
work environment to attract and retain skilled nurses?
Ms. Clifford. Yes, sir. And in VA nursing we actually use
an expert panel for staffing methodology model, in which case
we use front-line staff to participate in what those staffing
levels and numbers should be for those individual units. That
is the model that we use. So we do involve front-line staff in
that, and they look at the demographics of their unit, the
turbulence of their unit, the things that are going on in their
unit, and the acuity levels to determine what should be the
appropriate staffing mix and level. And those recommendations
are then put forward through the nurse executive to the
resource committees at those.
Mr. Takano. Dr. Spagnolo, the similar question regarding
the ability to collectively bargain, to set staffing levels. Do
you think that expanding the collective bargaining rights and
physicians' ability to negotiate would play a role in ensuring
physicians' voices are heard, you are paid attention to by the
folks that are making decisions?
Dr. Spagnolo. Frankly, I am not sure I have an answer to
that question. We currently have union representation in the
hospital that gets involved in a lot. I think some of these
issues, it seems to me many times it makes it more complicated.
I think if we could empower more people within the hospital we
could probably eliminate a lot of these problems that have to
do with working conditions.
Mr. Takano. How do you empower them without having
collective organization? How are you going to be heard and
listened to? How are you going to get people to listen to you
unless there is some leverage?
Dr. Spagnolo. Well, I am not quite sure I understand that
question. But if you are talking about pay or are you talking
about working conditions?
Mr. Takano. Well, working conditions are also part of what
are collectively bargained.
Dr. Spagnolo. I am not sure, the issues that we have been
discussing here, I don't know if you need that kind of
collective bargaining agreement. I think if we can all sit down
around the table, we could solve these problems.
Mr. Takano. Okay. Thank you.
Mr. Spagnolo, I want to briefly ask you this question.
Isn't there a tremendous physician shortage in the country?
Does that not play into why it might be difficult for the VA to
recruit physicians?
Dr. Spagnolo. There is a physician shortage in some areas,
I agree with you on that.
Mr. Takano. Primary care?
Dr. Spagnolo. I think in primary care. But, again, I keep
coming back to the same issue, it is a revolving door, if you
don't make things a little better. I think the salaries in the
last 10 years have come up significantly.
Mr. Takano. Okay. On the physician's assistant side, I am
just wondering about whether or not there might be some
education inflation. I was interested to hear that the military
was the beginning of the whole idea of PAs. There are community
college programs that will take, up until now, PA people who
had up to 5 years of experience, say, in the military, and with
a community college program of 2 years they can become PAs, but
I understand that the accreditation has moved had a to a
master's degree minimum.
Ms. DaSilva. Yes, sir.
Mr. Takano. Is that something you agree with, Ms. DaSilva?
Ms. DaSilva. I went to a community college and applied to
an accredited physician assistant program. So it is at a
master's level now. The Grow Your Own, the ICT is a great
program and a great pathway to let returning corpsmen and
medics coming back who are OIF/OEF to have a pathway to go and
become physician assistants. So, yes, it is a master's program
now and it has to be accredited.
Mr. Takano. But is the loss of that pathway through the
community college to your program, is that a problem? I mean,
is that kind of added burden necessary?
Ms. DaSilva. Sir, when I applied to PA school, and to my
knowledge there is not a pathway that you can go to a community
college and become a physician assistant, it at a minimum was a
bachelor's program even when I applied in 1999. I did not know
of any community college that was offering the physician
assistant program at that time. There were very few even at
that time that were offering a bachelor's, they had all turned
to a master's program and now even offering doctorate's.
Mr. Takano. Thank you. I yield my time back.
Dr. Benishek. Thank you.
Dr. Wenstrup.
Dr. Wenstrup. Thank you, Mr. Chairman. And I want to thank
you and the ranking member for putting this panel together and
for all of you being here today. I think it is very insightful
and it provides us with a lot of opportunity to make things
better in the VA by hearing what you have to say today.
When I first got here 2 years ago, and this is before
Phoenix broke and everything else, coming from private practice
I was concerned, I remember asking Dr. Petzel if anybody on the
administrative staff have ever been in private practice where
they had to be in the black to keep their doors open and none
of them had. And I found that very significant and a key part,
especially when you talk about physician directors today being
involved. It would be even more helpful if they had some
private practice experience and prove efficiency.
I also asked the question at the time, I said: Do you think
the VA, if you took all their expenditures like a private
practice has to do, their physical plant, their nurses, their
assistants, their supplies, their insurance, and all the bills
that they had to pay, I said if the VA looked at themselves
that way and took fee-for-service at Medicare rates, would you
be in the black. And he said yes. And I about fell out of my
chair, because I know how tough it is to be in the black seeing
three times as many patients as the VA was doing.
And I greatly appreciate what you are talking about today,
where you have physicians doing things that in a private
practice you have someone else do, so that you can care for
more people. And that really is the bottom line. So I really
appreciate what you are saying today.
Look, on this committee alone we have five physicians. If
we can't make things better sitting here, then we are in
trouble. This is an opportunity that should not be wasted, and
I hope that we proceed in that direction. So thank you all for
advocating on the things that I think we all believe in.
I do have one question, and it has to do with retention and
recruitment and the length of time it takes to fill a spot. I
think we have touched on some of the reasons why it is tough,
but I am curious how long it takes to fill a spot. Because I
have had young doctors, podiatrists, M.D.s, come to me and say:
I looked into it, but I didn't see a bright future here. And
especially when you talked about the podiatry pay issue.
So if you could both weigh in on length of time it takes to
actually fill a slot on average and the challenges, I would
appreciate it.
Dr. Spagnolo. I don't know what else to tell you other than
the processes are so complicated and it has got to go through
so many levels and then it has to get approved and reapproved
and on a resource committee meeting and then off of committee,
and sometimes the committee doesn't meet for 2 months, and then
it goes to HR, and then back to the resource committee. That
just takes forever.
Dr. Wenstrup. Well, that is what I want to hear. And I am
hoping working with you we can come up with a plan that
streamlines that and makes it a whole lot more efficient.
Dr. Spagnolo. I would be delighted to help you work on that
plan.
Mr. Chairman, I have a clinic at 1 o'clock, which we have
40 people waiting on me. May I be excused?
Dr. Benishek. Yes, I suppose so.
Dr. Wenstrup. Well, Dr. Salvo, I would like you to weigh in
as well, if you can.
Dr. Salvo. Thank you. I am in complete agreement with Dr.
Spagnolo, and he indicated earlier in his testimony an
approximate wait time in terms of getting credentialed and
privileged and starting in the VA approximately 1 year. And if
I were to consider the average, that is probably true.
When I left my post in the Cleveland system, it was 14
months before that was filled. I have had two WOC (Without
Compensation) positions since have I started my current
position with APMA. One took me 11 months. The other one,
surprisingly, took me 5. It is an excessive, burdensome process
when you factor in VetPro and you factor in the application
process along with all of the forms and the various HR levels
and committees that everything has to be completed. So it is
extremely, excessively burdensome.
Dr. Wenstrup. Thank you very much for your testimony.
I yield back.
Dr. Benishek. Thank you, Doctor.
Ms. Kuster.
Ms. Kuster. Thank you very much to our chair and the vice
chair for holding this hearing.
And I apologize to all of you that we have flights that we
have to catch, but I appreciate you being here and look forward
perhaps another time that we could bring Dr. Lynch back so that
more of us could hear.
I just want to focus in. I had the opportunity just
recently to visit the White River Junction, Vermont, hospital,
which is the VA hospital that serves many of the folks in my
district. And I think they are very focused on veteran-centric
care. They have actually had some very good results from the
Choice Act in hiring just recently. In fact, they were focused
on getting nurse practitioners into our CBOC so that in the
rural communities they would have the prescribing ability to
stay on top of medications and prescribe without people having
to go down to the VA hospital.
But I want to focus in on the question of the PAs, and just
generally I am pretty familiar with the private sector and the
fact that this is a national trend, we are pushing down our
medical care to the right person, at the right time, for the
right task. So it doesn't surprise me that somebody would come
in and not see a physician. I don't typically see a physician
when I get care in the private sector. If I can see a PA or see
a nurse practitioner, I get terrific care. So I don't want to
mislead anyone about what is expected.
My concern about the PAs is this chronic loss rate, 12 to
14 percent loss rate, and particularly comparing it to a very
favorable practice with the nurse practitioners in their
residency program, 100 percent retention of employed nurses
after 1-year of employment, as compared to over a loss rate of
over 10 percent in other practices.
I am wondering, and this is for Ms. DaSilva, have you see
anywhere, whether it is in the VA or outside, it could be a
best practice that we could bring in, a residency-type program
where we could be more focused on our PAs, give them the
support that they need to be able to stay on the job, because
my understanding is it takes at least 6 months to replace a PA.
That is expensive. It is expensive to the system. And, as I
say, I am just focused on veteran-centric care. Can we get them
the care that they need?
Ms. DaSilva. Thank you for that great question.
The issue when you were talking about the residency
program, we don't have a particular, like, Grow Your Own
residency program. When I had given my verbal testimony, I
talked about the scholarships that are just not available. So
if you have a medical technician or somebody in the VA system
who says they want to go on and become a physician assistant,
there aren't really funds that are nationally set aside for it.
It is up to each local facility if they do that. There isn't a
definite program that you can apply to and have a pathway to
become a physician assistant.
So if you wanted to do that, you would have to take out
loans or leave the VA system or come into the VA system, spend
a short amount of time, and then leave. That is why we were
talking about the Grow Your Own. So if you do have corpsmen
medics who are in the VA system or returning, can come and work
at the VA, get their PA school paid for, and then continue to
work within the system.
That would be the ideal pathway to do and to set aside.
There are education debt-reduction programs to have PAs come
and work in the system. However, the funding is at a local
level, so it is not nationally mandated. So if you ask at the
local level, they may say that the funds are not available.
Ms. Kuster. So I would be very interested in looking into
bipartisan legislation to bring the PAs in line with both the
debt reduction and the scholarship programming too. And I love
the idea of our returning vets. I know we have talked a lot on
this committee about aligning their abilities and making sure
that they have a path to successful employment in the private
sector.
And then just briefly, my time is almost up, but I did want
to just mention I am also interested in the mandated surveys,
to include our PAs in the mandated salary surveys in the
community so that we better align the compensation for PAs. But
I think we should do what we can to make sure that doctors are
working at their highest and best use and that they have the
support to see more patients. I am a big fan of bringing in
nurse practitioners and nurses obviously for what they can do
for it. And I really want to be supportive of getting PAs up to
speed and well compensated so that they will be able to
participate as well.
So thank you very much.
And I yield back. Thank you.
Dr. Benishek. Thank you, Ms. Kuster.
Dr. Abraham, you are recognized.
Dr. Abraham. I first want to give Dr. Spagnolo who has left
accolades for having the patience of Job, if he is able to work
40 years in the system that requires him to enter data. I know
as a practicing physician when my triage nurse would call in,
or my scribe when we used the electronic health records would
call in sick, I would see two-thirds, if not 75 percent less
patients that day when I actually had to do the work. So the
hard work is actually done by those nurses and good triage
people that make us look better than we probably really are.
Saying that, I have worked also with PAs and NPs all my
career, and the service and the level of care that you provide
is outstanding.
Dr. Salvo, on the podiatry front, I have referred patients
all my career to podiatrists for anything from Charcot foot to
diabetic cultures, and again could not ask for a better level
of care from your profession. So kudos to you guys.
I find it odd that in programs such as Choice or anything
that is non-VA related that the VA doesn't mind that our good
veterans are being seen outside the VA clinic by board
certification other than ABMS. They allow the AOA, I think that
is the osteopathic board, and the ABPS, the profession that you
represent, Mr. Morris, they allow them to see them and don't
seem to have a problem with that, but they evidently have a
problem hiring those same types of board certifications in the
VA hospitals themselves.
Again, going back to my little world of a practicing
physician before this job, I used physicians of every specialty
certification, for hospitalists, for referral. And across the
board there was no difference in care. They all, whether it be
the ABMS, your profession that you represent, the AOA, all
provided, again, outstanding level of care, either outpatient
or in the hospital, for my patients.
So I guess the question is, how many physicians do you
think have been denied positions at the VA because of their
different board certification?
Mr. Morris. We couldn't get an accurate--I mean, there is a
lot of our membership, which is why we have been pushing this
issue. Most of them are even veterans themselves. We have tried
to reach out to get those counts, to get those numbers, but
unfortunately in the politics of medicine some of the
physicians are even afraid to even come forward to say things
because there are blacklists or names that get out to where if
they do get an opportunity to get a job, they have been denied
these instances.
The politics of medicine regarding board certification has
been something that I was shocked to see when I first came in.
If you are having great physicians denied opportunities or even
great physicians working within the VA system denied levels of
promotion, denied movement along in their career solely because
they chose the smaller board. And we are here today and we have
been here continuously having you meet our physicians to really
show them that it should be looked at the physician as a whole
of their education, training, and experience, not what choice
they made in their board certification.
Dr. Abraham. Thank you.
Mr. Chairman, I yield back.
Dr. Benishek. Thank you.
Well, I think everyone has had an opportunity. So if there
are any further questions, otherwise we will excuse the panel.
Well, you all are excused then. Thank you very much for
your testimony. We really appreciate you coming in here.
Dr. Benishek. I will now welcome our second panel to the
witness table. Joining us in the second panel is Dr. Thomas
Lynch, the VA Assistant Deputy Under Secretary for Health for
Clinical Operations. Dr. Lynch is accompanied by Elias
Hernandez, the Deputy Chief Officer for Workforce Management
and Consulting, and Dr. Gage, the Chief Officer of Nursing.
Thank you all for being here.
Once you get settled, Dr. Lynch, you are welcome to begin
your testimony.
STATEMENT OF THOMAS LYNCH, M.D., ASSISTANT DEPUTY UNDER
SECRETARY FOR HEALTH FOR CLINICAL OPERATIONS, VETERANS HEALTH
ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS,
ACCOMPANIED BY ELIAS HERNANDEZ, DEPUTY CHIEF OFFICER FOR
WORKFORCE MANAGEMENT AND CONSULTING, VETERANS HEALTH
ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS, AND DONNA
GAGE, PH.D., RN, NE-BC, CHIEF OFFICER OF NURSING, VETERANS
HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS
OPENING STATEMENT OF THOMAS LYNCH M.D.
Dr. Lynch. Thank you, Mr. Chairman. I think I got the short
chair here, but I will try to make the best of it.
I would like to go off script for just a minute after
acknowledging you, Mr. Chairman, Ranking Member Brownley, and
the members, and thanking you for the opportunity to discuss
VA's ability to recruit onboard and retain qualified medical
professionals.
I want to acknowledge the panel that preceded us. I want to
acknowledge the opportunities that they afforded us I want to
hear. I wanted to echo Secretary McDonald's statement of the
other day that we really need to engage and empower our
employees. We need to listen and we need to learn because they
will help us provide better care to veterans.
With that said, I would also like to acknowledge today that
I am accompanied by Mr. Elias Hernandez, Dr. Donna Gage. Mr.
Hernandez was recently appointed Chief Officer for VHA's Office
of Workforce Management and Consulting and is responsible for
providing human resource support services and training. Dr.
Gage, who recently joined VA from the private sector, serves as
VHA's Chief Nursing Officer and advises on all matters related
to nursing and the delivery the patient care services.
Establishing and realizing staffing requirements for VA's
healthcare system is a very complex task. The VA operates over
1,000 points of care across the country and provides a full
range of primary and specialty care services for patients
ranging in age from our youngest, recently discharged
servicemembers to our most senior veterans. Rural populations,
unique health conditions resulting from combat experiences, and
an increasing number of women veterans require a commensurate
array of professionals to address their unique and individual
requirements.
Adding to the challenge is the fact that there are many
approaches to medical professional and support staff modeling
across large healthcare systems. There is no one-size-fits-all
model and no single set of staffing management tools from the
private sector or elsewhere that we can borrow. These are
indeed challenges, but they are no means an insurmountable
barrier to achieving the goal of timely access to care for
veterans.
VA is leveraging our national recruitment program,
dedicated recruiters partnering with facilities and identifying
hard-to-fill positions, marketing, and hiring qualified medical
professionals. We are promoting scholarships and loan repayment
programs, such as the Education Debt Reduction Program and
employee incentive scholarship programs, as expanded by VACA.
We have increased the physician and dentist compensation pay
tables in order to attract and retain qualified healthcare
providers. We are improving the credentialing process for VA
and DoD healthcare providers, which involves sharing
credentials to speed up the process.
In the last 12 months, VA has hired more than 37,000 new
employees, with a net increase of over 11,000 medical
professionals and staff. This includes about 1,000 physicians
and 3,000 nurses.
In addition, we are leveraging new technology to expand the
reach of healthcare providers. From 2010 to 2014, there was a
114 percent increase in the use of all healthcare technology
among unique veterans. At the end of 2014, 12.7 percent of all
veterans enrolled in VA care received telehealth-based care.
This includes over 2 million telehealth visits, touching
700,000 veterans.
To address the increase in the rural veteran population,
the VA's Office of Academic Affiliations, in partnership with
the Office of Rural Health, is sponsoring a 3-year Rural Health
Training Initiative. The project is designed to fulfill VA's
mission to serve veterans living in rural areas. Funding under
this request allows VA facilities to expand health professions
training to rural VA locations. Additional trainee positions
awarded as part of this initiative become part of each
facility's permanent base location.
As you can see, we have made significant progress, but we
realize we still face many challenges with wait times, the
provision of rural healthcare, and the commitment to women's
health issues. By increasing staff, clinical space, community
care, and the hours of care available we believe our recent
progress has resulted in some increases in the number of unique
patient visits and large increases in the number of
appointments for veterans already enrolled. We have completed
2.5 million more appointments inside VA this past year.
We also believe that in many specific locations, with the
longest wait times, the more access we offer, the more veterans
will seek VHA care services. It is also a challenge to recruit
healthcare professionals at some of these locations. These are
all contributing factors as to why wait times are stagnant in
some areas and why we must focus our efforts.
In conclusion, Mr. Chairman, we have the best clients in
the field of healthcare. We are grateful for Congress' support,
and we look forward to your continued assistance in getting the
best doctors and nurses to serve veterans. The challenges
remain formidable, but our commitment to timely, accessible
care and a positive patient experience is unwavering.
Mr. Chairman, this concludes my opening remarks. My
colleagues and I are prepared to answer any questions you and
the members of the committee may have.
[The prepared statement of Dr. Lynch appears in the
Appendix]
Dr. Benishek. Thank you, Dr. Lynch. And I will yield myself
5 minutes for questions.
It is great that you come and you tell us how well you are
doing and how much improved and you cite these statistics and
stuff, but it is really frustrating to me. You heard the
testimony from the previous panel and that there seems to be
just way too many orders from above about how things get done
within the VA and that there is not enough, what Dr. Spagnolo
talked about, is that the people on the ground who are actually
taking care of the patients get to make some decisions that
affect how the process works.
Now, the VA provides hospitals, and this bureaucratic mess
does not occur at the same level in private hospitals. So not
every single private hospital has 2,000 clinics, but they seem
to do a better job of hiring and firing and having processes
work efficiently than the VA. And I think a lot of it is
because the people on the ground have more power to actually
change things.
Now, I will give you a great example of this, is I just
went to a CBOC in my district, and one of the complaints that I
had was that everybody who went and saw the patient had to sign
in and out on the computer. There was a computer in the examine
room, the nurse goes in, she has to sign into the computer, she
has to sign out when she is done. The doctor comes in, he has
got to sign in and sign out to write anything down about the
patient. They can't take their laptop with them and stay signed
in. They have to wait 5 minutes signing in every time they see
a different patient. And it was like the cumulative time of
signing in and signing out of the computer was, a huge waste.
So the people in the clinic are telling me that this is a
big time killer in their clinic and yet nobody could get that
changed, because the way they were doing it was from above.
Those are the kind of processes, Dr. Lynch, that need to be
solved at the local level because every single little clinic or
hospital is going to have an issue like that that has to be
done.
And I have been here for years now listening to what you
guys have been doing as far as physician staffing, for example,
eight times in the last 30 years the inspector general has told
the VA that they need a central plan for hiring physicians and
eight times the VA has agreed with the inspector general that
they need that. But they haven't gotten a central plan for
hiring physicians over the last 30 years.
So what has changed, Dr. Lynch? How can we get this moving?
How can we jump-start this? I mean, it is the same answers I
hear. It is not working.
Dr. Lynch. So let me start by agreeing with you on one
point. I think the aggravation of dealing with our computer
system is exceedingly frustrating. I think the other side of
that, fortunately, is that it provides a very accurate medical
record.
I would disagree in that I think the solution is probably
central and we need to look for ways to make computer access
more efficient across our system. I don't think it is a local
problem. I think it is larger.
Dr. Benishek. Well, I could tell you that at the hospital I
worked at I had a laptop of my own that I used. I signed in
once, I kept it with me, and I went and saw a bunch of
different patients. I didn't have to sign in and sign out. That
was not a centrally planned decision, that was a locally
planned decision, and it was a lot better for everybody. The
nurse had her computer at the nursing station. She just went
back and forth and didn't have to sign in and sign out, lose
your spot, all that baloney.
And somehow you can't solve that simple problem? But your
answer is it has to be solved centrally. That is the wrong
answer, Dr. Lynch. That is what I am trying to tell you.
Dr. Lynch. I understand your position, but I am going to
disagree. And we end up facing obstacles from Homeland
Security, and the risk of access to national computers limits--
--
Dr. Benishek. Everybody has a problem with the security of
health computers, so don't tell me it is special to you, okay,
because everybody is concerned about the patients' privacy on
healthcare. So these are answers that don't make any sense, Dr.
Lynch, and I am very disappointed to hear this kind of stuff. I
want your solution to these problems, and I think it goes down
to not having enough control locally.
Mr. Hernandez, let me ask you a quick question before I am
out of time about Ms. Clifford's HR question and statement that
it is so unwieldy. What can you do about? Quick.
Mr. Hernandez. Thank you, Mr. Chairman.
I will tell you, Mr. Chairman, and to acknowledge to the
subcommittee that we do have a complex HR system which is
comprised of two different personnel----
Dr. Benishek. What have you done in the last year to change
that?
Mr. Hernandez. We have trained the HR professionals, the
credentialers, the leaders of the organization, and the hiring
managers at the local level to understand the hiring process
and the roles and responsibilities during that process.
Dr. Benishek. Have they changed that process in the last
year to make it simpler?
Mr. Hernandez. Sir, we are looking. Mr. Sherman----
Dr. Benishek. You have not then, that is a no, you have not
changed the process in the last year to make it simpler.
Mr. Hernandez. We have, Mr. Chairman.
Dr. Benishek. What have you done?
Mr. Hernandez. We have visited the----
Dr. Benishek. What have you changed in the process of
hiring people in the last year that made it simpler, one thing?
Mr. Hernandez. We have educated the H.R. community----
Dr. Benishek. No, no, no, not educate the person. What
about the process have you changed in the last year to make the
hiring easier?
Mr. Hernandez. That is what I am trying to convey, Mr.
Chairman, that the hiring authority that we have given to us by
Choice, as well as the flexibilities that we have of hiring
Title 38 and Title 38 hybrid occupation is being fully utilized
systemwide.
Dr. Benishek. Okay. I am out of time. I am sorry.
Ms. Brownley. Thank you, Mr. Chairman.
Well just to follow up on that line of questioning, I think
Mr. O'Rourke asked the first panel, what is a big, major thing?
That is what he was looking for, something big and a big
change. And Ms. Clifford answered by saying it is human
resources. And I think, and I think this is what the chairman
was getting after as well, is that there are so many rules that
you have to follow that that really slows the process down.
So to me it is the rules, and we probably need more human
beings and human resources to carry out the task and the
mission of the amount of people that we need to hire within the
VA, which many would say is insurmountable. It is a huge number
that we need to hire.
So can you address, is there anything underway to evaluate
rules that might have been made two decades ago that can be
changed, rules that can be changed, and what we can do to hire
more in human resources to get this engine running at a higher
speed to hire new professionals within the organization?
Mr. Hernandez. Yes. Ranking Member Brownley, there have
been numerous engagements at the local level by subject matter
experts from the national level to provide support in terms of
the processes that we currently have.
And I would like to state this, because it is very
important, and perhaps it may look like a simple issue. But we
have integrated the requirements identification at the local
level with the responsibilities of the human resources
professionals, as well as the hiring managers, the people that
are responsible for space and equipment, and the individuals
responsible for the credentialing process. Where at one time
those processes used to be independent and used to operate in
silos, we have integrated those particular processes so we
don't have the delays that the other panel mentioned to the
subcommittee earlier. And we have proven that in Phoenix, we
have proven that, the process has worked in St. Louis.
Ms. Brownley. Okay, so you have gotten rid of silos and
there is a more integrated process, where in certain areas in
the country we are speeding up the process. Have you had any
directive from above to say we need to really review the rules
within human resources and adding additional personnel? And is
anything like that underway?
Mr. Hernandez. Yes, ma'am. I will tell you that last year
the Leading Access and Scheduling Initiative looked at the
processes and the barriers that we had in the local level in
terms of HR and as well as the national level, and we were able
to change a lot of the VHA policies that were identified as
barriers.
In terms of the human resources situation that we currently
have, we are looking at that particular process in terms of
bringing up that particular issue to the national level
committee so that we can address that particular situation.
Ms. Brownley. But have you had a specific directive to hire
additional people and continue to make changes within the rural
process to streamline the whole hiring process? You have had
directives?
Mr. Hernandez. We have had guidance issued to the field,
yes, ma'am.
Ms. Brownley. So, Dr. Lynch, in terms of the testimony from
the American Podiatry Association, is there something that we
need to do legislatively to fix what they testified in? And if
there is not a need for a legislative fix, is there something
the Department can do to recognize their growing mission? And I
think they also testified vis-`-vis their salaries, et cetera.
So how do we get more podiatrists within the VA? Do we need to
fix that legislatively or can that by fixed internally?
Dr. Lynch. So let me first acknowledge the work that
podiatrists do. As a vascular surgeon, I have worked closely
with podiatrists throughout my career and I appreciate the
value of their product.
There have been several suggestions that have been
provided. One was suggested this morning that VA be given the
authority to recognize podiatrists as physicians, as CMS does.
Other changes are to our handbooks. But it appears that one of
the more significant opportunities may be legislation, and we
are more than happy to work with the committee to provide the
clinical input to the development of any legislation that may
bring that forward.
Ms. Brownley. Thank you. I will yield back.
Dr. Benishek. Dr. Wenstrup.
Dr. Wenstrup. Thank you, Mr. Chairman.
Dr. Lynch, you said something that really struck, and it is
not on you, but what you said is there are homeland security
issues. And I think what a shame it is that the veteran going
to the doctor becomes a homeland security issue. And that tells
me that we have become way too connected in everything that we
do with the core of the Federal Government that when you go to
the doctor you have to have these issues.
Because I can tell you from many years in my practice, may
be changed since we have had to use EMR forced on us by the
government and connect with all these people and people's
medical records are now going everywhere rather than staying
within your office, but I can tell you, for years any
individual, veteran or otherwise, that came to me for care
wasn't worried about Russia, China, North Korea, or Iran.
We need to have a solution to that problem, and you are in
the middle of it, and I would love to hear some solutions,
because that should not be a concern of veteran, that it is a
homeland security issue for them to go to the doctor.
Dr. Lynch. Congressman, I don't disagree with you, and I am
as frustrated as you are.
Dr. Wenstrup. I am sure you are.
Dr. Lynch. And I have lived it, okay, and I don't know what
the solutions are, but I agree entirely that we need to figure
out a way that we can streamline the medical care system that
now has the opportunity to use virtual technologies and not let
it get tied up in security issues that actually create more
work rather than less work.
Dr. Wenstrup. But I agree with Dr. Benishek, and it is the
same on DoD side from personal experience. You are putting your
CAC card in a million times a day rather than seeing patients
and you are going back and forth. I mean, the difference, in my
practice if somebody comes, they tell a medical assistant there
is someone up front, what is wrong with them, how they injured
themselves. They turned their ankle, we go get an x-ray.
Haven't seen the doctor yet. Now they see the doctor, the x-ray
is there. I hadn't had to plug in three times to make that
happen and do that from patient to patient.
Let us help you help fix this problem by coming up with
solutions that we can insist that the VA make changes. And I
know as a practicing physician, if you have had to experience
that or know the difference, help us come up with the solutions
and demand that we get it done.
Dr. Lynch. Yes, sir.
Dr. Wenstrup. Thank you. I yield back.
Mr. Takano. Thank you, Mr. Chairman.
Dr. Lynch, in your testimony you mentioned that as a result
of the Choice Act the VA has already hired 2,500 medical
professionals and support staff. Did I get that right?
Dr. Lynch. Twenty-six hundred actually, yes.
Mr. Takano. Twenty-six hundred. Were all of those new
positions or were some of those staff hired to fill existing
vacancies?
Dr. Lynch. To my knowledge those were new positions.
Mr. Hernandez. New positions.
Dr. Lynch. New positions.
Mr. Takano. Okay. Well, with the resources the Choice Act
provided will the VA be able to shorten the long wait time it
takes to fill the vacancies at the VA?
Dr. Lynch. I am confident they are. I think Mr. Hernandez
implied earlier that human resources has begun looking at their
process. It has in the past been a serial process. It needs to
be a parallel process. It can be complex, but it can be
simplified. It requires proactively assessing our needs. In
certain cases it requires staffing to organizational charts. We
know somebody is going to leave, we know that position is
approved, let's replace it. It involves communication, it
involves preparation.
I think, to the chairman's point, this is where the
clinical staff does need to get involved with the leadership
and with human resources to further the efficiency of the
process that we currently have. It is not efficient, it takes
too long. I think we know how to change it. I think we have
begun to implement changes. We need to go further.
Mr. Takano. Another vital provision of the Choice Act was
the increase of 1,500 GME slots. I understand that the first
round of residencies have already been awarded.
Dr. Lynch. Yes, sir.
Mr. Takano. And that the VA is moving forward with the
second round.
Dr. Lynch. Yes, sir.
Mr. Takano. Will expanding the number of residencies
improve the pool of candidates for the vacancies at the VA?
Dr. Lynch. Absolutely. Two standpoints. Number one, I think
VA has a unique advantage over the private sector. Currently,
we have over 40,000 residents and medical students that rotate
through our VA. We have nurses as well. These are all potential
employees. We have first chance at evaluating those
individuals. We just need to be able to efficiently move to
hire them.
What the Choice Act did was to give us more positions in
primary care and mental health in rural areas and in areas
where there is not access to care. The goal will be to train
people in communities where they may go back to practice. VA
once again has the opportunity to say: Let's try to look for
the best and let's hire them for the VA, but let's do it
efficiently.
Mr. Takano. You know what, I did get a call from a
gastroenterologist, a young one, working at the USC medical
facility in Los Angeles, and expressed extreme frustration at
not being communicated with. This person has applied for a
vacancy at gastroenterology at the LA VA hospital. And so I am
beginning to understand what made on Hawaii this frustration.
What do we need to do to bring through this inefficiency? I
mean, do you have a plan? Have you pinpointed where the
bottlenecks are?
Dr. Lynch. The bottlenecks, Congressman, are the fact that
we don't move fast enough and that we don't give people
commitment soon enough. I was talking to Mr. Hernandez before
the subcommittee hearing, and we have mechanisms in place now
where we can offer a job a year in advance of the completion of
their program. That means we can identify the people we want,
we can offer them the job. The only condition is that they have
to complete their training. But otherwise, we have an
opportunity to take advantage of these educational training
programs that we have. And we haven't been doing it, but we
need to.
Elias, do you want to comment briefly on how we can begin
to recruit and get these people sooner?
Mr. Hernandez. Yes. Thank you, Dr. Lynch.
Going back to my original point is taking advantage of the
flexibilities we have on the Title 38 and Title 38 hybrids
appointing authority. We can engage in early conversations with
the residents so we can get their commitments with the
condition that once they complete their training program we
will be able to convert them into permanent employees for the
organization.
Mr. Takano. What about people who already are trained and
certified and are applying for vacancies?
Mr. Hernandez. Congressman, I will tell you that we have a
very aggressive national recruitment program, and I, personally
speaking, would like to know a little bit more about that
particular individual because gastroenterology is one of the
most critical occupations we have in the organization. And our
national recruiters are dedicated staff that deal directly with
those individuals to engage with them early on in the process
and walk them through the entire onboarding process.
Mr. Takano. I will be happy to furnish the names to you.
Mr. Hernandez. I would love to have it, Congressman.
Dr. Benishek. Thank you. Thank you.
Well, it is just funny that they are solving the problem,
but your guy can't get a job after a year.
Dr. Abraham.
Dr. Abraham. I will add my frustration to Dr. Benishek's
and to Dr. Wenstrup and evidently the panel's about having to
log in every time that patient goes from room to room. Homeland
security was one issue that you brought up, Dr. Lynch, but
certainly on the civilian side we as physicians have to worry
about HIPAA compliance if we let a record escape. The fines are
very hefty. So we are under the gun, so to speak, as much the
VA is and we understand.
But if we have a computer system in the VA facility that
the record can't move from computer to computer, then we do
have a problem. And I am sure that they can, but the reason
that they don't is I guess a question I do have, is like Dr.
Benishek said, why can't that computer travel with the patient
or just travel from room to room as the patient travels, just
boot that record to another facility? The first question.
And the second question, I only have two, you heard Mr.
Morris' testimony, he was representing, I think, the American
Board of Physician Specialties, as far as not being able to
receive jobs in I guess the ratio that the ABMS was able to
with their certification. Is there a disparity between those
two specialties and even the AOA, the osteopathic physicians,
and if so, why?
Dr. Lynch. Congressman, I will be honest, this is the first
I have heard of the concern today. I take it seriously because
it is the potential opportunity to find more healthcare
providers for the VA and for veterans. I will take it for the
record to go back and find out a little more information about
that and what has happened in the past.
Dr. Abraham. I would appreciate if you would send that to
me or just a followup. I would appreciate that.
Dr. Lynch. Absolutely.
Dr. Abraham. Okay. And the first question, what is the
issue with the computers?
Dr. Lynch. I share your frustration.
Dr. Abraham. I know you do.
Dr. Lynch. I have been there.
Dr. Abraham. We are past Alexander Graham Bell and we
actually have got some pretty good computers these days.
Dr. Lynch. I grew up in an era when the phones were still
dial and actually in an era when you had party lines, which was
always kind of interesting.
Dr. Abraham. I was also there.
Dr. Lynch. I can carry a phone in my pocket now. We need to
figure out a way how we can harness computers to work for us
and not necessarily create obstacles for us.
Mr. Abraham. And I appreciate that. And again, my request
is that you please look into that, because it shouldn't be that
hard with the computer systems we have now.
Mr. Chairman, I yield back.
Dr. Benishek. Thank you.
Anyone have any other questions?
Go ahead.
Ms. Brownley. I just wanted to make one final comment
before we close here. And I just want to say I know that the
employees within the VA, particularly in human services, and
you, Mr. Hernandez, are working very, very hard every day. Ms.
Clifford testified that you are working really hard every
single day, and I believe that and I thank you for your
service.
I just believe that we need to do more, that you need more
assistance, you need a larger team, and we have to streamline
the rules that are made, and we have got to put on our
commonsense thinking hats, if you will, and streamline this
process.
So I didn't want to close without you thinking that,
because I believe that you are working very, very hard and the
people who are working for you are working very, very hard. I
just believe you need more people and we need to improve upon
the rules.
Mr. Hernandez. Thank you, ma'am, and we appreciate your
support.
Dr. Benishek. Thank you all once again for being here
today. I think we have touched on several issues that are very
important for our veterans, and I really appreciate the work
that you do.
The subcommittee may be submitting additional questions for
the record. I would appreciate your assistance in ensuring an
expedient response to those inquiries.
Dr. Benishek. And if there are no further questions, the
panel is excused. Thank you very much.
Dr. Benishek. I ask unanimous consent that all members have
5 legislative days to revise and extend their remarks and
include extraneous material. Without objection, so ordered.
Dr. Benishek. I would like to once again thank all of our
witnesses and the audience members for joining us here this
morning and this afternoon. And the hearing is now adjourned.
[Whereupon, at 1:02 p.m., the subcommittee was adjourned.]
APPENDIX
Prepared Statement of Joan Clifford, MSM, RN, FACHE
Overcoming Barriers to More Efficient and Effective VA Staffing
Chairman Benishek, Ranking Member Brownley and members of the
Subcommittee, 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 testify on today's important and timely subject--VA
Staffing.
As the Department of Veterans' Affairs undergoes a system-wide
reorganization to include the many challenges of implementing The
Veterans Access, Choice and Accountability Act, staffing must be at the
forefront of its evaluation. I am Joan Clifford, Deputy Nurse Executive
at the VA Boston Health Care System and am here today as the immediate
Past President of NOVA. NOVA is a professional organization for
registered nurses employed by the VA.
NOVA respects and appreciates what our labor organizations do for
VA nurses. NOVA's focus is on professional issues not working
conditions which are the purview of the union.
NOVA is uniquely qualified to share its views on the ability of VA
to effectively and efficiently recruit, on-board and retain qualified
health care professionals to treat our veteran patients. As VA nurses,
we are in the medical centers, community-based outpatient clinics and
at the bedside every day. With this in mind, we have identified
retention and recruitment of health care professionals as a critically
important issue in providing the best care anywhere for our veterans
and would like to offer the following observations.
NOVA believes that the underlying issues reside in the lack of a
strong infrastructure for Human Resources, insufficient nursing
education opportunities, as well as the complex application system--USA
Jobs--that the VHA utilizes for hiring staff.
VHA is facing a shortage of both corporate experience, and a lack
of sufficient HR staffing to support the multiple priorities required
for hiring health care professionals.
USA Jobs is a complex hiring process. The system is very slow to
review applications online, adding days, even weeks to the time it
takes to create a complete qualification review. Upcoming enhancements
in HR such as Web HR and HR Smart have to be able to interface with USA
Jobs. Some candidates have had to wait five months while HR processed
their applications. This results in candidates accepting non-VA jobs,
and puts VA back in the hunt for another qualified candidate.
HR employees often have limited knowledge of direct hiring process
for Registered Nurses, resulting in unnecessary recruitment delays. HR
has also been faced with multiple initiatives, policies and Human
Resources Management letters with unclear instructions and guidance.
Additionally, current VA process and policies for obtaining recruitment
and retention incentives can also cause significant delays in hiring
personnel.
All levels of support personnel, as well as RN's, are impacted by
the current inflexibilities in pay structure and years of flat lined
and non-existent pay increases. Reclassification and downgrades of some
occupations such as Surgical Technicians who were brought in at the GS7
level, and have recently been downgraded to GS5 are making it
impossible to competitively recruit and retain. Additionally, the
increased availability of private sector jobs due to retirements and
program expansions within the Affordable Care Act has created other
hurdles for VA.
Locality pay challenges, which directly influences RN pay, have
once again been brought up by Medical Center leadership. Due to the
lack of corporate knowledge among staff within HR on how to maximize
the law inconsistent application of the Pay Law remains an obstacle of
hiring. NOVA asks that the ceiling on nurse pay be increased to prevent
compression between the grades in order to remain competitive.
Ensuring an infrastructure of knowledgeable education leaders
within VHA is also critical to support programs that produce nursing
graduates who honor and respect Veterans Programs. These programs are
often key to hiring opportunities at the Post Baccalaureate Nurse
residency and the Nurse Practitioner residency level within VA.
Nursing residents from these programs are embedded in the VA and
have the opportunity to demonstrate clinical competency as well as
apply for available positions. An increase to the nursing education
infrastructure budget is needed to provide for more senior nursing
leaders who initiate and manage these programs.
Tuition reimbursement and loan forgiveness monies should also be
enhanced in order to help new nurses defray the cost of their education
if they work for VHA. The Office of Academic Affairs has supported a
wonderful RN Residency Program across some VA's, but funds are limited
thus potentially impacting the recruitment of future RN hires who flock
to these programs. Programs that already exist, such as the Health
Professional Scholarship Programs, which allow the VA to recruit nurses
by paying their tuition in exchange for a service commitment after
licensure, need to be considered an important part of funding
methodology.
Funding is also needed to support VA Nursing Academic partnerships
which enables VA and School of Nursing faculty to develop and implement
Post Baccalaureate Nurse Residency (PBNR) and Nurse Practitioner
Residency programs (NPRP). The PBNR has had an impressive impact on
nursing recruitment and retention. The PBNR had 100% retention of
employed nurses after one year of employment as compared to the overall
loss rate of 10% in other practices. The nurse practitioner residency
program has found that residents overwhelming wish to work in the VA.
The NPRP program is currently a pilot and will require sustained
funding to pay for resident stipends and education infrastructure for
the educational programs and infrastructure for VA Nursing. NOVA
believes it is a good investment as hiring NP's will increase access
and enable additional services to veterans needing care nationwide.
Another area of concern is the use of Advanced Practice Nurses
(APRNs), which at this time, are subject to the state laws in which the
facility is located. If a state has a physician supervisory or
collaborative relationship in their regulations, then APRNs are not
allowed to practice autonomously to the full scope of their abilities.
Currently there are 20 states and the District of Columbia that have
Full Practice Authority laws in place; in those states and the
district, VA APRNs are allowed to practice to the full extent of their
scope. However, in the other remaining states this is not permissible.
VHA is advocating for ``Full Practice Authority'' which would
result in APRNs employed by the VA to function to the full extent of
their education, licensure, and training, regardless of what state they
live and work. Legislation has been introduced, H.R. 1247, the
``Improving Veterans Access to Care Act of 2015,'' which is the model
already practiced by the Department of Defense, Indian Health Service
and the Public Health Service systems. NOVA, together with the American
Nurses Association, American Association of Colleges of Nursing,
American Association of Nurse Practitioners, American Association of
Nurse Anesthetists, National Association of Clinical Nurse Specialists
and the American College of Nurse-Midwives are calling on Congress to
support this legislation which would begin to address critical needs
within VA facilities by improving wait times and access to care for all
veterans.
In closing, NOVA would like to add that the past year's negative
publicity surrounding the scheduling and access crisis within VA has
also had an impact on recruiting potential applicants. VA employs over
90,000 nurses, which is about one third of its health care workforce.
NOVA believes that there is no greater time to have representatives
from the Office of Nursing Services at the table as VA reorganizes the
way it provides care and services to America's heroes
Improvements and careful review of the process of downgrades across
VA, increased training and utilization of Locality Pay law, revising
the cap on the RN Pay schedule to eliminate compression, as well as
establishing a more user friendly application process and supporting HR
offices across the U.S. will go a long way towards correcting the
challenges VHA faces with staffing.
NOVA once again thanks you for this opportunity to testify and I
would be pleased to answer any questions from the committee.
Statement on Receipt of Grants or Contract Funds: Neither Ms. Joan
Clifford, nor the organization she represents, the Nurses Organization
of Veterans Affairs, has received federal grant or contract funds
relevant to the subject matter of this testimony during the current or
past two fiscal years.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Prepared Statement of Dr. Nichol L. Salvo
Chairman Benishek, Ranking Member Brownley and members of the
Subcommittee, I welcome and appreciate the opportunity to testify
before you today on behalf of the American Podiatric Medical
Association (APMA). I commend this Subcommittee for its 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. Nichol Salvo, member and Director of Young Physicians' at
the American Podiatric Medical Association (APMA). I am also a
practicing VA physician, maintaining a Without Compensation (WOC)
appointment status. I am before you today representing 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 in my capacity today, I do bring with me 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. Chairman, when the Veterans Health Administration (VHA)
qualification standards for podiatry were written and adopted in 1976,
I was not yet born. 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 thirty-nine 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 597 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 equitable 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 I was born. 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 my patient population, Mr. Chairman. I serve patients who
are statistically comorbid with psychosocial and socioeconomic issues,
all of which play a role in my delivery of care and final outcome. I
know first-hand, with private practice experience and VA experience,
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,
400,000 with sensory neuropathy, and 70,000 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. From FY 2001
to 2014, the number of foot ulcers increased in the OEF, OIF, and OND
populations from 17 documented cases to 612 (12). Despite our
statistics of at-risk patients, lower extremity amputation rates among
all veteran patients decreased from approximately 11,600 to 4,300
between fiscal year 2000 and 2014 (12). 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 2014, the foot and ankle surgical procedures rendered by the
podiatry services totaled 4,794, while foot and ankle surgical
procedures performed by the orthopedic surgery service was a sum total
of 72.
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, Site Director for Surgical
Service, Department of Veterans Affairs - New York Harbor
Health Care System;
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; and
Eugene Goldman, DPM formerly the Associate Chief of
Staff for Education at Lebanon VA;
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
mine. 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. I am speaking from personal experience, Mr. Chairman. As stated
earlier, I am one of the majority. I entered the VA with less than five
years of experience and was not board certified at the time. I gained
my experience, earned my board certification, and separated from the VA
to take a leadership position with my parent organization. I will
forever remain loyal to VA, which is why I still voluntarily treat
patients at my local facility, without compensation. Having worked
inside and outside the VA, I can truly attest to the disparity that
exists.
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. I am personally aware that my position was assumed
by a podiatric physician 14 months after my separation. 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. My credentialing process for my recent two without
compensation (WOC) appointments was 11 months and 5 months,
respectively. Those are 16 months of missed opportunity to treat
patients, but instead, I was needlessly waiting, as were the patients
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.
Five 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 come before 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. Chairman and members of the Subcommittee, thank you
again for this opportunity. This concludes my testimony and I am
available to answer your questions.
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12. Preventing Amputation in Veterans Everywhere (PAVE) Program
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