[House Hearing, 114 Congress]
[From the U.S. Government Publishing Office]
EVALUATING VA PRIMARY CARE DELIVERY, WORKLOAD, AND COST
=======================================================================
HEARING
before the
SUBCOMMITTEE ON HEALTH
of the
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED FOURTEENTH CONGRESS
FIRST SESSION
__________
THURSDAY, OCTOBER 22, 2015
__________
Serial No. 114-39
__________
Printed for the use of the Committee on Veterans' Affairs
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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
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C O N T E N T S
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Thursday, October 22, 2015
Page
Evaluating VA Primary Care Delivery, Workload, and Cost.......... 1
OPENING STATEMENT
Dan Benishek, Chairman........................................... 1
Hon. Mark Takano................................................. 3
WITNESSES
Randall B. Williamson, Director, Healthcare, GAO................. 4
Prepared Statement........................................... 25
Thomas Lynch M.D., Assistant Deputy Under Secretary for Health
Clinical Operations, VHA, U.S. Department of Veterans Affairs.. 5
Prepared Statement........................................... 36
Accompanied by:
Richard C. Stark M.D., Director of Primary Care
Operations, VHA, U.S. Department of Veterans Affairs,
And
Gordon Schectman M.D., Chief Consultant for Primary Care
Services, VHA, U.S. Department of Veterans Affair
EVALUATING VA PRIMARY CARE DELIVERY, WORKLOAD, AND COST
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Thursday, October 22, 2015
U.S. House of Representatives
Committee on Veterans' Affairs
Subcommittee on Health
Washington, D.C.
The subcommittee met, pursuant to notice, at 10:00 a.m., in
Room 334, Cannon House Office Building, Hon. Dan Benishek
[chairman of the subcommittee] presiding.
Present: Representatives Benishek, Bilirakis, Roe,
Huelskamp, Coffman, Wenstrup, Abraham, Takano, Ruiz, and
Kuster.
Also Present: Representative Walorski.
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
our friend and colleague and member of the full committee,
Congresswoman Jackie Walorski, to sit on the dais and
participate in today's hearing. And she will be joining us
shortly. Without any objection, so ordered.
Thank you all for joining us for today's subcommittee
hearing Evaluating VA Primary Care Delivery, Workload, and
Cost.
During today's hearing, we will be discussing the findings
and recommendations of a Government Accountability Office
report regarding the primary care that is provided to veteran
patients at Department of Veterans Affairs' medical facilities
across the country.
I was glad to join many of my fellow committee members in
requesting this report which will be publicly released today
and I commend the GAO for their work.
During their investigation, the GAO found the department
lacked reliable data on how many patients VA primary care
providers were seeing. The GAO also found that VA had failed to
put appropriate oversight processes in place to verify whether
the primary care data that the VA medical facilities were
reporting was accurate or to monitor the primary care that was
being provided to veteran patients.
For six of the seven VA medical facilities that the GAO
visited, panel size varied from a low of a thousand patients
per provider to a high of 1,338 patients per provider. The GAO
found that the cost of the care in VA primary care clinics also
varied widely.
VA has been unable to respond to repeated requests for cost
of care information by me and other members of this committee
for more than a year now.
But the GAO found that in fiscal year 2014, VA expenditures
per primary care encounter ranged from a low of $150 to a high
of $396 across the system and expenditures per patient ranged
from a low of $558 to a high of $1,544.
Data inaccuracies, oversight, and management failures and a
lack of continuity or uniformity in care or costs across the
country have sadly come to characterize the VA healthcare
system over the last several years.
Nonetheless, the GAO findings are alarming. For many
veteran patients, an appointment with the primary care clinic
is the first appointment they have at a VA medical facility.
For them, primary care is the gateway to VA care.
Without accurate data and effective oversight, the VA
cannot guarantee that VA primary care providers are
productively providing high-quality care or that veteran
patients are receiving timely access to care. And without
minimizing variations in costs across the system, the VA cannot
guarantee that primary care is being delivered efficiently from
VA facility to VA facility.
My suspicion based on my 20 years of work as a contract
physician at a rural VA medical center and three years as
chairman of this subcommittee is that primary care is not being
provided efficiently or effectively at far too many VA medical
facilities and as a result, far too many of our veterans are
falling through the cracks.
Meanwhile, software that could have addressed some of VA's
primary care data reliability issues were shelved after the
department had spent almost $9 million on it supposedly because
of a lack of the one and a half million dollars in funding that
was required to implement it nationally.
What is more, the department plans to take until September
of 2016 to issue new primary care guidance and until September
of 2018 before findings and decisions regarding primary care
encounter and expenditure data to strengthen primary care
monitoring will be made.
That is unacceptable particularly considering that GAO
reported that some providers at facilities with high panel
sizes have already expressed to VA medical center leadership
that their ability to provide safe and effective patient care
was being hindered by their workload.
The VA must take action today to protect VA primary care
patients and to help VA doctors and nurses provide higher
quality care to our Nation's veterans.
I will now yield to Mr. Takano who is sitting in today for
our ranking member, Ms. Brownley, for any opening statement he
may have.
OPENING STATEMENT OF HON. MARK TAKANO
Mr. Takano. Thank you, Mr. Chairman, for calling this
hearing. Thank you.
Today the subcommittee is looking at the efficiency and
effectiveness of the department's ability to deliver primary
care to veterans enrolled in VA's primary care.
Since 2010, VA has provided primary care services through a
patient-centric medical home model of care called the patient
aligned care teams or PACTs. The PACT teams are made up of
physicians, nurse practitioners, physician assistants as well
as support staff. This model is designed to improve access,
continuity, and care coordination among other things.
Many veterans seeking mental health services have
benefitted from this model because they have not been subjected
to the stigma attached to visiting a mental health clinic.
While we have worked hard to destigmatize mental health, I
understand this is still a challenge for many veterans.
In its written testimony, VA reminds us that it is
difficult to compare VA's enrollee population to that of the
private sector. VA patients are older and sicker than their
counterparts and overall, 20 percent have documented mental
health diagnoses.
In order to get the right care to the right veteran, the VA
needs to know how many veterans are being treated at each
facility. The report the GAO released today found that VA data
on primary care panel sizes are unreliable and that proper
oversight mechanisms are not in place.
Due to the absence of reliable panel size data and
oversight processes, GAO concluded that this could
significantly inhibit VA's ability to ensure that facilities
are providing veterans with timely quality care that is
delivered efficiently. GAO also found that VA was in violation
of federal internal control standards.
As you know, Mr. Chairman, VA's primary mission is to
provide high-quality, safe healthcare to veterans. A top
priority for this subcommittee is to ensure that VA has the
tools and resources it needs to enable that to happen.
I thank the witnesses for their testimony and I look
forward to hearing from our panel.
Thank you, Mr. Chairman. I yield back the balance of my
time.
Dr. Benishek. Thank you.
Joining us on our first and only panel this morning is
Randy Williamson, Director of Healthcare for the Government
Accountability Office.
We are also joined by Dr. Thomas Lynch, the VA Assistant
Deputy Under Secretary for Health Clinical Operations. And Dr.
Lynch is accompanied by Dr. Richard Stark, the VA Director of
Primary Care Operations, and Dr. Gordon Schectman, the VA Chief
Consultant for Primary Care Services.
Thank you all for being here this morning.
Mr. Williamson, we will begin with you. Please proceed with
your testimony.
STATEMENT OF RANDALL B. WILLIAMSON
Mr. Williamson. Thank you, Mr. Chairman and Mr. Takano and
members of the subcommittee.
I am pleased to be here today to discuss GAO's report
released today on VA's processes for determining and overseeing
workload capacity of its primary care teams at its medical
centers.
Primary care services are often the entry point to the VA
healthcare system for veterans and these services are delivered
by primary care teams consisting of physicians, nurses, and
support staff.
Determining how many patients to which each primary care
team can reasonably deliver care referred to as the panel size
is critical to ensure that our Nation's veterans receive
timely, quality care and is delivered in an efficient manner.
For example, if panel sizes are too high for primary care
teams at a particular facility, this may lead to veterans
experiencing delays in receiving care, whereas low panel sizes
may be associated with inefficiency and wasted resources.
To better ensure that VAMCs have reasonable primary care
panel sizes, VAMCs are required to record and report panel size
data including the number of primary care providers, support
staff, and available exam rooms.
VA's central office inputs these data into a model it
developed, determines the appropriate primary care panel sizes
for each VAMC, and provides this data to VAMCs. However, VAMCs
can deviate from these model panel sizes as they see fit.
We attempted to compare VA's model panel sizes with actual
panel sizes for all of its VAMCs, but we found that systemwide,
some data that VAMCs record and report to central office were
inaccurate and unreliable.
For example, panel size data included patients who had died
or who had not been seen in the last two years. Also, there
were missing data and the number of reported exam rooms were
sometimes erroneous. Absent accurately reported data, VA's
central office has no good way of determining whether primary
care panel sizes are too high or too low.
We conducted detailed reviews at seven VAMCs and after
correcting reported inaccuracies at six of them, we found that
actual panel sizes ranged from 23 percent below to 11 percent
above the model panel sizes that central office determined to
be appropriate at these locations.
Panel sizes for these VAMCs ranged from a thousand patients
per full-time providers to 1,338. VAMC officials attributed the
differences to varying degrees of patient demand, staffing
shortages, and/or exam room shortages.
Some VAMCs decided to establish lower panel sizes to
prevent provider burnout and attrition. Other VAMCs with higher
panel sizes were experiencing staff shortages due to recruiting
and retention difficulties associated with rural locations or
the inability to compete with higher pay offered by the private
sector. Also, some VAMCs were not affiliated with a university
medical school that could have provided a supplementary pool of
physicians.
We also found that cost for primary care visits which can
be an important measure of how efficiently primary care is
being delivered varied widely at VAMCs. The cost per primary
care visit varied from $158 to $330 at the seven sites that we
visited.
We also found that oversight to better ensure accuracy of
data VA submit is basically lacking. Moreover, even if accurate
primary care panel size data existed, neither VA's central
office nor many VISNs perform systematic oversight to identify
large gaps between the model panel sizes and the actual panel
sizes at its facilities.
Also, cost per visit data is not even considered to be
relevant as a measure of how well VAMCs are managing the
delivery of primary care services.
Absent meaningful oversight to correct potential imbalances
in primary care panel sizes, some VAMCs may be putting veterans
at risk by not providing timely, quality care.
For example, one VAMC we reviewed with the highest panel
size, 1,338, had a vacancy rate among its primary care
providers of 40 percent. Some primary care providers at that
facility expressed concern to VAMC leadership that the high
panel sizes were impeding their ability to provide safe and
effective primary care services.
This situation is all too reminiscent of veterans' access
issues that have arisen at other VAMCs in the recent past. The
problems with poor data and insufficient oversight that we
noted in the report are precisely why GAO added VHA to our high
risk earlier this year.
To correct the issues we noted in this study, we made
several recommendations to improve data accuracy and establish
a more robust oversight process. While VA concurred with our
recommendations, we are concerned that VA may not be moving
fast enough to make needed improvements. Without major
improvements, VA is likely missing opportunities to identify
VAMCs that warrant further examination and to strengthen the
efficiency and effectiveness of primary care.
This concludes my opening remarks.
[The statement of Randall B. Williamson appears in the
Appendix]
Dr. Benishek. Thank you, Mr. Williamson. I appreciate it.
Dr. Lynch, please go ahead.
THOMAS LYNCH, M.D., ASSISTANT DEPUTY UNDER SECRETARY FOR HEALTH
CLINICAL OPERATIONS, VETERANS HEALTH ADMINISTRATION, U.S.
DEPARTMENT OF VETERANS AFFAIRS, ACCOMPANIED BY RICHARD C.
STARK, M.D., DIRECTOR OF PRIMARY CARE OPERATIONS, VETERANS
HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS, AND
GORDON SCHECTMAN, M.D., CHIEF CONSULTANT FOR PRIMARY CARE
SERVICES, VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF
VETERANS AFFAIRS
STATEMENT OF THOMAS LYNCH
Dr. Lynch. Good morning, Mr. Chairman, Congressman Takano,
members of the committee. Thank you for the invitation to
discuss the delivery of primary care services to veteran
patients by the Department of Veterans Affairs.
I am accompanied today by Dr. Richard Stark to my left and
Dr. Gordon Schectman to my far left.
Mr. Chairman, VHA has over 5.3 million veterans enrolled in
primary care. We have almost a thousand sites of care and over
half of the patients receive care in community-based outpatient
clinics near their homes.
In many rural areas, we provide care via telemedicine or in
mobile medical units. In recent years, we have implemented
extended hours and all patients have access to after-hours
medical advice call centers.
The majority of our patient population has multiple chronic
diseases. VA patients are generally older, more complex, less
healthy, and less socioeconomically well off than those in the
private sector. Veterans have a higher prevalence of common
chronic health conditions such as diabetes, hypertension, and
heart disease.
Overall, 20 percent of veterans have documented mental
health diagnoses and most of our primary care sites have
integrated mental health capabilities so that patients do not
have to travel for routine mental health care. In addition, our
primary care teams have training and experience identifying and
managing combat-related sequela such as TBI or PTSD.
Beginning in 2010, as Congressman Takano mentioned, VA
began providing primary care through the patient-centered
medical home model of care. VA refers to these as patient
aligned care teams or PACTs and they involve a team-based
approach to healthcare.
Through the PACT, patient care is not only provided in
person in our clinics but also through virtual modalities such
as by telephone, email, or by telemedicine. This team-based
model is also being used to explore new venues of providing
primary care including the provision of care in the home
through video technology and the use of scribes in the clinic
setting to enhance provider productivity and patient
satisfaction.
The more than 8,000 PACTs are made up of a variety of
clinical and clerical staff including physicians, nurses, and
clinical assistants. It has been demonstrated that patients who
have been placed in well-implemented PACTs have lower hospital
readmission rates, improved levels of patient satisfaction, and
higher results on measures of quality of care.
Overall, VHA exceeds the private sector in outpatient
measures of quality such as preventive care and the management
of diabetes and cardiovascular disease.
While facilities must have the flexibility to adjust panel
size based on local resources and patient complexity, central
oversight is also important. And reliable panel sizes are
essential to assure continuity and coordination of care.
VA is appreciative of GAO's findings in this regard and
agrees that greater oversight and responsibility for the
accuracy of data are needed. Through the changes recommended,
our processes to identify and manage instances of significant
variation will be strengthened.
Primary care leadership in VA has also recognized the
issues of our aging data systems and that this has been a
contributing factor with regards to inaccurate documentation
and the monitoring of panel size.
In response to this issue, a redesign and reengineering of
the software that tracks and helps manage patients, the primary
care management module has been underway and will begin full
deployment this year. The updated database will enable both
greater control over the accuracy and reliability of panel data
and more granular and precise data about staffing and space.
The report by the GAO also found that primary care cost
data reported by VHA facilities were reliable but subject to
variability. And we concur with the GAO's assessment that VA is
missing an opportunity to potentially improve the efficiency of
primary care service delivery through heightened oversight of
encounter use and costs.
When considering cost, it is important, however, to note
that the comprehensive integrated services offered by PACT are
generally not present in the private sector. PACTs offer
integrated mental healthcare, social services, coordination
with non-VA care as well as prevention and wellness support.
However, many of these services are housed in medical
centers which are often aging and not properly configured for
efficient outpatient care. This makes cost comparisons with
non-VA care models difficult to accomplish.
Mr. Chairman, VA continues to be a veteran-centric
organization and to deliver patient-centered, world-class
healthcare.
This concludes my testimony and we look forward to further
discussing VA primary care with the members of the committee.
[The prepared statement of Thomas Lynch appears in the
Appendix]
Dr. Benishek. Thank you, Dr. Lynch.
I will yield myself five minutes for questioning.
Mr. Williamson, this struck me as a result of these data
inaccuracies, you only calculated actual panel sizes for six of
the seven selected facilities where you were able to use
updated data provided by each facility and corrected for
inaccuracies.
So the data that the VA gave you initially, that was not
adequate for you to do any analysis at all; is that right?
Mr. Williamson. Correct. We got data from VA, and we looked
at it and did some further investigation. And we saw a number
of outliers that just didn't look right. And as we explored
those at the sites that we reviewed in detail, we found out
indeed there weren't accurate.
One of the biggest issues was that there were a number of
people included in the panel sizes that either had died or had
not been seen in VA for the last two years.
Dr. Benishek. So this data that the VA gave to you, Dr.
Lynch, that is the same data you used to analyze what is going
on there?
Dr. Lynch. I think, Mr. Chairman, VA has made some
significant changes since this report was put together. And we
would be happy to discuss those further with you.
Dr. Benishek. Well, it is just of concern to me, while I
would like to know what those are, but it is of concern to me
that, Mr. Williamson says that the data you are collecting
isn't useful without going over it a second time and fixing it
up so that it made some use. So that is of great concern to me.
And, you know, one of the things I have been trying to do
in this committee is to try to get the VA to collect more data.
The panel size to me, I don't know that that is the biggest
issue other than the fact that it is a guide to how many
providers you need, but certainly I think there should be some
discretion at the local level to decide what the panel size
should be so that you prevent this burnout issue and that 1,200
might not be the right number. It may be different in different
areas, so I can understand that.
What I am concerned about, though, is a little bit about
the cost per visit. That seems to be a more important part of
it because it is difficult for me to figure out. I don't
pretend that there should be the same cost per visit as it is
in the private sector for many of the reasons that both of you
discussed.
But does the cost of the visit, does that include the
facility's charges, too? I mean, like the rent of the place
that you are at or the cost of the building and the utilities,
is that all a factor in that?
Mr. Williamson. It includes everything including
depreciation on VA buildings.
I would also like, Mr. Chairman, to go back to something
Mr. Lynch said. The VA data that VA gave us is still flawed. I
mean, the data that VA has in the system and probably the
figures that VA gave you just now is based on flawed data.
The improvements that VA have planned including, the new
PCMM software will correct a lot of the data problems, but the
improvements have not been implemented yet. And I take issue
with the fact that significant improvements have been made, as
Dr. Lynch suggests.
Dr. Benishek. Well, right. I mean, that is the whole basis
of this hearing is the fact that they may be making plans on
data that has no validity. And then to make a plan then when
the change in the plan doesn't work, then there is a surprise
and, you know, it is a problem. But I am just concerned about
the variability in the cost.
Mr. Williamson. Yes.
Dr. Benishek. And as I understand it, the variability took
into account already the variability based on location.
Mr. Williamson. Right.
Dr. Benishek. And I don't understand why there is such a
huge difference in the cost.
Mr. Williamson. Well, some of the reasons we were given
when we performed detailed work at the seven facilities, for
example, was that some facilities used telehealth and telephone
calls extensively while others don't. And that is one reason
why a facility may show lower costs.
Dr. Benishek. Does the data include like the severity of
the visit or the severity of illness of a patient and degree of
complexity of the visit? That is not included in this from what
I can tell.
Mr. Williamson. No. It is just basically the cost; that is
all the costs associated with that particular encounter and the
encounter itself.
Dr. Benishek. So, Dr. Lynch, does the VA collect any of
that data? I mean, like Medicare when you do a patient visit,
you have to check the complexity of the visit. Does that happen
in the VA?
Dr. Lynch. Yes, sir, it does.
Dr. Benishek. So where is that data? I haven't seen
anything.
Dr. Lynch. So I guess I would ask Mr. Williamson whether
their data was raw data or whether they adjusted for
differences between facilities in terms of the age of the
facility or the complexity of the patient.
Mr. Williamson. We adjusted for geographical labor costs
because labor costs are a big factor. Say from Los Angeles
versus St. Cloud, there is a very big difference in labor
costs. So we adjusted for labor costs and then used VA data for
that.
Dr. Lynch. But for age of the facility or complexity of the
patient population, there probably needs to be some adjustments
as well.
Mr. Williamson. That is right. That is the reason that you
want to, if you see big variations, to determine the reasons
for variations and that is why VA oversight would help identify
possible inefficiencies that may be happening at VAMCS. Yes,
there are a number of reasons why those costs could vary.
Dr. Benishek. Do you have the data on the complexity of the
patient visits, Dr. Lynch?
Dr. Lynch. We do, sir.
Dr. Benishek. It would be helpful, I think, for the
subcommittee to see like what is the average intensity level of
the visit because there is--I don't remember exactly the
numbers. Maybe Dr. Abraham remembers. He is closer to private
practice than I was, you know, because they have level one,
two, three, four, five outpatient visit.
And, you know, I can understand having complex patients
that have a higher complexity would cost more, but I think we
need to have that information on a regular basis to sort of
monitor and supervise how the VA is taking care of patients.
Is there a way of doing that on a regular basis, Dr. Lynch?
Dr. Lynch. I would hope we can find a way. Speaking as a
clinician, I don't disagree with you. I think the more data we
have to identify how best to treat patients, the better off we
are going to be. So I am not arguing with anything you are
saying.
I think with respect to the GAO report, we are aware of a
number of the deficiencies. The PCMM model which either Dr.
Stark or Dr. Schectman can speak further about will help us
basically look at panels and make sure they are properly
impaneled. It will help us work through and eliminate those
patients who may have died or may not have used VA care. These
are all important things. We need to know that and you probably
need to know it as a committee.
Dr. Benishek. I am sorry. I realize I am over time. I will
yield now to Mr. Takano.
Mr. Takano. Thank you, Mr. Chairman.
Mr. Williamson, did I hear you correctly? The chairman
asked a question that I am interested in about the
underutilized space and how that factors into your conclusions.
Did that factor into the cost of care?
Mr. Williamson. No, it didn't. As you know, many VA
facilities are old and were built when VA had more of an
inpatient model, and since VA has converted to an outpatient
model, the issue of shortage of exam rooms has came up quite a
bit. But, in looking at cost per encounter, it is going to be
hard to factor in exam rooms unless you do a specific analysis
of that facility.
Basically, just used the data that VA gave us.
Mr. Takano. So you didn't factor in the----
Mr. Williamson. No.
Mr. Takano. So the cost differentials wouldn't----
Mr. Williamson. No.
Mr. Takano. Okay.
Mr. Williamson. We used labor costs.
Mr. Takano. Okay. Dr. Lynch, the report references a pilot
project regarding primary care management model at the primary
care operations office at selected facilities in 2014. It was
mentioned in the chairman's opening statement. It was planned
to be implemented agency-wide after resolving certain software
interoperability issues.
Why is the implementation on hold and when will it be
implemented systemwide?
Dr. Lynch. So I am going to pass this off to Dr. Stark, but
I want to make the point it is no longer on hold.
Dr. Stark.
Mr. Takano. It is being implemented now?
Dr. Lynch. It is in the process of being implemented.
Mr. Takano. Okay. Dr. Stark, go ahead.
Dr. Stark. Yes. The PCMM web which is what we call the new
software that we have developed was deployed at four pilot
sites a little over a year ago. As a result of that deployment,
some problems with interoperability were identified and further
work needed to be done.
It was determined that that extra work would result in
additional funds being needed to complete the contract.
Mr. Takano. Is $1.5 million?
Dr. Stark. That is the $1.5 million.
Mr. Takano. Were you able to find that or----
Dr. Stark. Yes.
Mr. Takano [continuing]. You were able to implement?
Dr. Stark. Yes. The Office of Information Technology had to
pull money from a number of other projects and identified some
excess funding. And they were able to locate that funding and
were back on track. And really that resulted in a delay of only
two or three weeks in the deployment schedule.
Mr. Takano. Okay. So we are moving ahead with an improved
data collection? This concern over data that is not adequate
for the GAO, the VA is moving ahead with trying to resolve
that?
Dr. Stark. Yes. This software has been a long time coming.
And one of the reasons for developing it was to correct some of
the issues that we had with inaccurate data and replacing the
old software that had really been in place for 15 or 20 years
and had been patched in all kinds of ways over the course----
Mr. Takano. Well, this is news I wasn't expecting to hear.
I am glad to hear that VA is moving forward with improved data
collection so that we can get a better handle on per patient
costs.
You know, the GAO has also found that the VA was in
violation of federal internal control standards. Dr. Lynch,
what are you doing to ensure compliance going forward with
those standards?
Dr. Lynch. The VA is taking this very seriously. Dr.
Carolyn Clancy who is the interim under secretary for over a
year has taken that on as one of her tasks to begin addressing
the concerns that GAO has that have placed us on the high-risk
list. And that includes looking at policies and implementation
of our policies and assuring that we have proper data
resources.
Mr. Takano. Dr. Lynch, I am very concerned about something
that has been said in previous testimony in different hearings.
I understand from testimony by a man named Mr. Giroir or it
could have been Ms. Giroir, I don't remember the gender, but
this person testified that 43 percent of network directors had
acting director status. Sixteen percent of VHA medical centers
lack a permanent director. More than two-thirds of network
directors, nurse executives, and chiefs of staffs are eligible
for retirement, so two-thirds of those existing staffers, as
are 47 percent of medical center directors.
As you try to address a topic like this of meeting
compliance, which to me is a managerial challenge--I know very
well what happened when I was on the board of a community
college and we had an acting chancellor and how that acting
chancellor was limited in their ability to actually move the
institution forward if we had acting presidents of campuses.
But having acting directors of almost half, I have to
imagine that this has an impact on your ability to make sure
that we are in compliance with a standard like this.
Dr. Lynch. It does and VA is moving to fill those positions
as rapidly as we can. And we appreciate the help that Congress
and the committees have given us in creating the leeway to do
that. But you are absolutely correct. We need to fill those
positions. We need to get permanent managers in position and
help us move the system forward.
Mr. Takano. Well, I know you have a challenge because I
understand that frequently administrators are compensated at 70
percent below the private sector for comparable positions, but
I also understand that it has been a real challenge within the
VA in terms of personnel and your personnel office in a number
of different respects. But I would say this is a very critical
thing with, you know, so many acting administrators.
Dr. Lynch. Two things, I think. Number one, there is a bill
that is currently under consideration which would allow us to
use the hybrid Title 38 designation for medical center
directors, non-physician medical center directors, which will
help us increase salaries, make positions more desirable. I
think we already have one of the most desirable missions of any
healthcare system in the country, which is treating veterans.
And I think we have been working with H.R. to try to develop a
more efficient process to hire people. We recognize those as
challenges and we have been trying to work on those, sir.
Mr. Takano. I thank you, Mr. Chairman for indulging me, and
I thank you for your testimony.
Dr. Benishek. I hesitate to say anything because I ran over
too. Dr. Roe?
Dr. Roe. Thank you, Mr. Chairman. And thank you all for
being here today. And the whole point of this hearing is how to
more efficiently provide care for veterans. It is primary care,
which is the entry level for most folks. And the entire country
now, medical profession, is undergoing a transformation. Many
of us on this panel this morning who are physicians started our
morning out with the American Group Medical Association,
representing 175,000 private practice doctors around the
country. And they are figuring out with ACOs and the new
payment models, which is pay for performance and outcomes, how
to negotiate this and how to become more efficient. And I think
the VA may still be stuck in the older model. And it really
needs to look at what is going on out in the private sector.
I want to look at, Dr. Lynch you said a couple of things
about the VA panels are older and sicker and so forth. Well I
just looked up at the NIH website while you were saying this
and 18.5 percent of the population in general 18 and over have
mental illness. It does not mean they are in treatment but they
have mental illness. So the incidence is the same as the VA.
And if you look at the incidence of a soldier recruited today
versus the population in general, they are the same. So I do
not know that, and I know Mr. Williamson we have had an
opportunity to talk. And I think that in your testimony you
stated that the demographics of the VA patients, at least Dr.
Lynch did in VA's written testimony, are consistently different
from a majority of the private primary care practices. Is that
data accurate? Because I do not believe that it is. I think
taking care of veterans is like taking care of any other
patient.
Mr. Williamson. Well as far as setting the panel size at
1,200, which is kind of the rule of thumb for VA, VA did an
extensive literature search. They made adjustments because of
the acuity of older patients. They set panel sizes lower than
the private sector. I am not here to tell you that is right or
wrong but that is the reason and the rationale that they gave
us.
Dr. Roe. And a typical panel, and I will just tell you
having practiced medicine for 31 years many doctors under-code
in the private sector. And I will, as we go around, you will
find out that we under-code what is actually done so our data
may not be accurate either. You think, well, I do not want
Medicare to come in and look at all this. So I mean, I know
that I probably under-coded----
Mr. Williamson. Yes.
Dr. Roe [continuing]. The severity of the illness of the
patients I was taking care of. I heard Dr. Lynch, and I want to
expand on this a little bit because I believe you all are on to
something by helping make these panel sizes. Look, the panel
size we know with VA is about half the size that it is in
private practice approximately. And I think you can increase
the efficiency and the satisfaction of practice by having
someone do two things. One is provide an adequate space for the
doctors to work, and then an adequate support staff. An
adequate support staff, I mean, let the doctor be the doctor.
And the scribe you are talking about I think every office visit
I make practically now is that there will be someone there to
enter the data into the computer. It is an added cost for a
practice but I also think it adds tremendous efficiencies. How
many places, how many scribes are you actually, because the
medical center where I am in Johnson City, Tennessee, I do not
think there are any.
Dr. Lynch. I am going to ask Dr. Schectman to address that
question.
Dr. Schectman. So the concept of using scribes to enhance
efficiency, productivity, is a very attractive one. We have
explored what is happening in the private sector in order to
understand better and we have really networked with the
advocates of this. There are scribes here and there in the VA
but what we have done is established a formal pilot in order
to----
Dr. Roe. There isn't, is not a formal pilot? I think the
Secretary said there was the other day.
Dr. Schectman. No, no, no, there is. I am saying we have,
what we have a pilot ongoing now to evaluate scribes----
Dr. Roe. Where? Where and how many?
Dr. Schectman. There are currently three sites and only
about four or five providers.
Dr. Roe. How many? Four or five?
Dr. Schectman. Right. So it is a limited----
Dr. Roe. So it is nothing.
Dr. Schectman. It is limited.
Dr. Roe. That would be pretty limited when you----
Dr. Schectman. Well, but we are, we are planning on
expanding it. We have sites who are interested in participating
and we are planning to add them. And also including a
comparison with voice technology so that we can really see
whether or not----
Dr. Roe. Again, the motivation I think is different. Just
to give you an example, all of us up here are private
practitioners. And if I am going to see 25 or 30 people a day,
and I have got an electronic health record that takes me two
minutes or three minutes longer to do that than it does, I have
added an hour and a half so that the last patient is an hour
and a half late. The VA does not, I do not know how many they
saw, but I did just some quick calculations. If you have a
panel of 1,000 and you see ten people a day, which is not
really hitting it too hard, that is 2,000 visits a year based
on ten months. And that is two visits per person, per year.
Which as Mr. Williamson said, some people are in and out. And I
admit, it is hard. So I mean, patients of mine died too and I
did not know it till they did not come in a year or two and I
saw their obituary in the paper. I get that is hard to figure
out. But you will after a year or two figure it out when they
have not been in. You make a phone call and find out. That is
what we did, you have not been in for your appointment.
Dr. Schectman. We agree with the need to explore this
further.
Dr. Roe. Okay and thank you. I yield back, Mr. Chairman.
Dr. Benishek. Ms. Kuster.
Ms. Kuster. Thank you, Mr. Chairman, and thank you to our
panel for being with us. One of the questions that I wanted to
explore has not been discussed yet, and if it is not in the
realm of this conversation I am happy to move on. But I know we
have heard on this panel before about the difficulties with
scheduling. And it occurs to me that that is one of the primary
obstacles to running an efficient panel, is knowing that when a
physician comes in in the morning they are going to be seeing
people throughout the day and they are not going to be waiting
for appointments that were canceled. It seems to me a couple of
years ago I spoke with a vendor who had a very efficient
system. They just scheduled the most likely to show up in the
morning, the less likely to show up in the middle of the day,
and the least likely to show up at the end of the day when they
can double or triple book and make for a much more efficient
day. And I just had a question, is that taken into
consideration or is it something that is being considered going
forward so that the physicians that we do have can work in an
efficient way?
Dr. Lynch. So that specific model, no. But I will let you
know that VA has awarded the contract for our new medical
scheduling appointment program. It will be pilot tested in
Boise, Idaho to assure that it delivers what we expected it to
deliver. We are also in the process of implementing some
scheduling enhancements, which will be rolled out over the next
six months to help our schedulers work more efficiently and
provide better scheduling opportunities.
VA has also looked at the no show rate, the missed
opportunity rate. We have several initiatives in place. We do
have a program and an algorithm that allows us to identify
those patients that are most likely not to show up for an
appointment. Right now the strategy we are using is to try to
contact those patients and confirm their appointment. But
certainly it would be worth looking at different scheduling
alternatives to see if that would be a useful technique as
well.
Ms. Kuster. And absolutely contacting the patients. I
remember I was shocked to hear that that had not been going on.
So I think all of us in the civilian world rely on that
reminder, even if it is an automated call.
My other question has to do with the associate providers
and the use of associate providers, PAs, medical assistants,
nurses, and the like. Did you look into that in terms of
efficiency or were you solely focused on the physician panels?
Dr. Lynch. I am going to let Dr. Stark take a shot at that.
Dr. Stark. Yes, currently about 30 percent of our primary
care providers are non-physicians, so they are nurse
practitioners which I think is about 24 percent, and physician
assistants are about six percent. So we make extensive use of
those other healthcare professions in primary care and they
have been very helpful to us in helping us meet the demand.
Ms. Kuster. And are they folded into your data? Is a
typical panel for a nurse practitioner also 1,200 patients?
Dr. Stark. No. Actually the panel size for a nurse
practitioner or a physician assistant is generally set at about
75 percent of a physician panel. And but nevertheless those,
that data is part of the panel capacity information that we
use. So we take that into account.
Ms. Kuster. And then the last question I have has to do,
again, efficiency speaking on behalf of the VISN, the hospital
in White River Junction, Vermont. I am in New Hampshire, but
most of my veteran constituents in the northern part of the
state go to the Vermont facility. They are having wonderful
success with telemedicine. I was surprised to learn actually in
mental health, very, very effective. Patients, vets are very
comfortable once they get settled into the chair and have the
eye contact. Did you take that into account? And is that a
direction that other VISNs could follow for greater efficiency,
greater effectiveness, and keeping costs down?
Dr. Stark. Absolutely. We have used telemedicine in a
number of our sites, particularly in rural areas where it is
difficult to recruit providers. You know, telemedicine can
really serve a lot of the needs of veterans without requiring
that face to face visit. In some places they have even set up
sort of telemedicine hubs where they hire it easier to hire
staff in a particular location. Those providers see a panel of
patients at a distant location on a regular basis. So it is an
effective tool, absolutely.
Ms. Kuster. My time is up. But I would also note that they
are having great success with PT, physical therapy, in a
distant location, which I was impressed by. People could just
stay at home. So thank you very much. Thank you, Mr. Chair.
Dr. Benishek. Dr. Abraham, you are recognized.
Dr. Abraham. Thank you, Mr. Chairman. I thank the panel for
being here, and I think we have got three primary care docs
here, and then a health director here. So this is a good
captive audience, and I am going to hit this from the private
sector like Dr. Roe did.
Mr. Williamson, you said that these hospitals that were
built back in the sixties and seventies were more built for our
inpatient population, and we get that. But when we are having
veterans wait too long to get an appointment, when they get
there too long to see the doc or the NP or the PA, you know, I
ran a multiphysician practice and I really did not care what
the docs or the NPs really cared about it, I cared about the
patient. And how hard would it be to open up, let us say, an
inpatient room, make that an exam room? You have got a bed, you
have got a couch. All you need is a stool for the doctor to
roll around in. I carry the otoscope in my right pocket and my
stethoscope in my left, and we are there. That is such a simple
thing to utilize a facility that you already have in place and
that you already are paying the electricity on anyway. So,
again, just, you know, common sense. The three docs can tell
you, we can convert that hospital room into an exam room in 15
minutes or less and be ready to go to work. And you know,
whether the NPs or the docs had to climb the stairs to get
there, that is not really, I really do not care as long as the
patient can get there and see somebody.
Going back to Dr. Roe's comment about the scribes and the
under-coding, and he is exactly right. Because we get so
wrapped up in not knowing how to use the software it takes us
forever to code a visit. A scribe is an expert. They have been
trained in that. And what I can tell you, we got scribes in my
practice, once we started using them we never over-coded but we
coded appropriately. Revenues went up. We saw more patients
because the scribe knew what they were doing better with the
software than we did. So Dr. Schectman, back to your comment. I
would advocate, and I can show you hard data across the nation
where scribes have enhanced profitability in the VA system or
in any system, any private business. But more importantly you
get to see more patients and you get to see more patients in a
very effective manner. You get to be the doc, as Dr. Roe said.
We are not typists and we are not certainly scribes.
And going back to data collection, we have got ICD-10 out
right now. And if you guys have looked at it, which I know you
have, ICD-10 has software where you can collect this data on
patients saying what their diagnosis is, what their treatment
outcome is.
So my point is this. I understand that, you know, you guys
are a government bureaucracy and you have to move a little
slower because you are dealing with taxpayer monies, and we get
that. But you know, I want to say that from the business model
point this is not nuclear physics or rocket science. This is
pretty simple stuff. And when we as private doctors have to
actually make a payroll and we are responsible for families
making a living and taking a paycheck home to their children,
we know how to do business. And the VA could do this. It is not
that hard.
So again, just more of a statement than a question. And
again, I think Dr. Lynch, you said something about voice
recognition software, we are trying to get it with the VA.
Well, you know we have got that. Dragon Speak or any of those
Dragon models, they have been working for 15 years and they are
wonderful. So, you know, in private industry all these things
are available and they are available now, and I think we need
to think about incorporating them into the VA system. Thank
you, Mr. Chairman.
Dr. Benishek. Thank you. Dr. Ruiz.
Dr. Ruiz. Thank you, Mr. Chairman, and Acting Ranking
Member for holding this. I am not a primary care doc, I am an
emergency medicine physician and we were born because the
system was broken and there was a high demand and people could
not see their doctors, or there was an emergency that needed
immediate care. And from there we developed efficiencies within
the emergency department to take care of the patients. When
there is not a bed, we use a gurney in the hallway. We double
up. We do whatever it takes to take care of the patients. And I
think that has always been my point, and that I want to stress
with the VA healthcare system, is that we need to move from an
institution centric system to a veteran centric, treat the
veteran first mentality and try to have all the flexibilities
that we can to make it work.
And in saying that I have done a lot of work with physician
shortages in rural areas in my district and others and I have
done research on this matter. And when you approach a physician
or a panel size difference for the healthcare provider there is
oftentimes a mentality where we need to look at this in the
perspective of the physician, in other words match the
patients, in other words call the patients the burden for the
physicians to create wellness in the physician's life so that
they can have a better experience, right? Or you can look at
this in a patient perspective and say we need to make sure that
we have the adequate amount of physicians in the pipelines and
train the physicians and the staff to meet the patient demand.
So there is a difference in the perspective. And I know that
you all understand that. I just want to make sure that that is
the central point, is that we are looking at this in the
perspective of the patients and in the short term utilize
whatever means necessary to get them the care, either in the VA
facility or outside of the VA facility. But give the care the
veterans need. Otherwise they will end up in the emergency
departments because they cannot see their doctors, or because
their diabetes got to an extreme point, or their mental health
has deteriorated and is to a point where they need to be
institutionalized.
And one of that things that our country has defined as an
adequate ratio in the community is one physician per 2,000
patients or people. To be considered medically underserved it
is one to 3,500. So my question to you is where do you get the
panel size of one to 1,200? And second is have you looked at
counting simply the full time equivalent physician for a VISN
per population, veteran population size of a VISN and just
utilize the one to 2,000 ratio to determine if you have enough
physicians within that VA system?
Dr. Lynch. Dr. Schectman, do you want to----
Dr. Schectman. I appreciate those comments. Regarding panel
size, there is controversy in terms of what is the right panel
size. I agree with you, a lot of the literature does suggest,
for example, the panel size should be 2,000 or greater. There
have been push back in the literature actually that this is too
much, that in fact this would require, in order to provide
comprehensive care the way the patient centered medical homes
do this would require providers working 20 hours a day really
in order to get all the preventive care done, as well as the
acute care, as well as the chronic care done. So the push back
has been to lower it. And this article that I am thinking
about, really, recommended lowering it to 1,700 or 1,800 for
the private sector but noted that in the VA due to the
complexity of the patients and other issues regarding the way
teams are configured and the way care is delivered that a panel
size of 1,200 or 1,300 is very, very appropriate.
You know, in fact the independent assessment reviewed this
very, very carefully and devoted pages to describing this issue
about what is the right panel size. And actually from the AAFP
took a formula which the AAFP is advocating and applied that to
the VA and came up with a panel size recommendation very, very
similar to our model panel capacity.
So I do not know considering all of the issues involved in
terms of panel size, I do not know if we are too far off the
mark. I think it is very hard to compare us to the private
sector without really a lot of, you know----
Dr. Ruiz. Well, there is different comparisons you can make
with different institutions that provide similar care and
departments that provide similar care for similar type patients
as the VA. I think the overall point here is what are you going
to do with the data? And second of all, do not wait for the
data to act. Do not wait for the data to get more physicians,
more ancillary staff. I mean, it is the common sense. It is the
patients that are waiting in the lobby. It is the patients that
have not been seen. It is the patients that are waiting that
need the care. So do not wait for the data. It is good to have
the data so you can make better decisions. But do not wait for
the data. And the end goal is to add more support for the
patients not to have a comfortable patient load to make the
physician's life better.
Dr. Schectman. I agree with you 100 percent.
Dr. Ruiz. Thank you.
Dr. Benishek. Thank you, Dr. Ruiz. I just want to make a
brief comment. And that is everyone is saying that the VA
patients are sicker, but you have not really shown us any data
to actually prove that. I mean, I understand that, having
worked in the VA. But you have not shown me a list of, you
know, the complications that people have. There is nothing like
that. So----
Dr. Lynch. I would refer you to Assessment A of the
independent assessment, which does address the issue of VA
demographics and does come to the conclusion that VA patients
have a higher comorbidity than those in the private sector.
Dr. Benishek. That is the data I would like to see.
Dr. Wenstrup. Thank you, Mr. Chairman. Thank you all for
being here today. I appreciate it. One of the things I am
trying to get a grasp on is we talk about this ratio of doctor
to patients in primary care. You know, it can vary from
practitioner to practitioner, and is there a local flexibility
to that? And also locally being able to try to figure out why
within the same facility one is able to see more than the other
and do it effectively. For example, in our practice, you know,
we had 26 doctors. If one is seeing 50 patients in a day and
another one is seeing 25 there may be a reason for it. It may
be as simple as you need another medical assistant, which more
than pays for itself, right? So I am just curious if there is
that flexibility on a local level to adjust depending, to
adjust in a couple ways, either give a practitioner more
patients if they are able or adjust how they are operating to
bring that level up?
Dr. Lynch. Dr. Stark.
Dr. Stark. Yes, there is definitely flexibility at the
local level. That is one of the things that is very important
to us, which is why our model panel sizes are basically
recommendations and kind of a starting point and then we allow
the local facility to adjust the panel sizes to the
characteristics of the practice, the characteristics of the
providers, the resources they have available so that they can
tailor their resources to what they have to make sure that
their veterans get the best of care.
Dr. Wenstrup. And are the supervisors or administrators of
these facilities keenly aware of this and working towards that?
Or does it take the practitioner to bring attention to it?
Dr. Stark. Well in most cases the primary care leadership
is very attuned to this and adjusts those panels on a regular
basis. And we provide them guidance on how to do that as well.
Dr. Wenstrup. You know, and there are some models that may
be similar to the VA setting. I mean, I understand the
difference between your typical private practice fee for
service, etcetera. But as far as the proper patient load, you
know it seems to me, I know in DoD, still serving in the
Reserve, there is this move, especially in the Army, that we do
not want to just be treatment facilities we want to be
healthcare facilities, and we want to be preemptive, and more
preventive, and things like that. But very often people do not
go to the doctor until they are sick and really we may do
better if we schedule appointments in like for example MDVIP,
which used to be owned by Proctor and Gamble. So Secretary
McDonald should be familiar with it. And it is a program where
people do pay a fee, but they come in even when they are well
to make sure that they are being kept up on their medicines and
things like that. And they limit their number of patients that
they see, and they still do some fee for service type things,
but things that are not covered. Well, you know, in the VA it
is pretty much all covered. So is there a drive towards this?
Doctor, you are shaking your head. So please weigh in on that.
Dr. Schectman. Well actually I was thinking more in terms
of a comment you made before in terms of developing better
regulation, panel management, and so on, and the fact is that
being deployed everywhere and so on. And in response, you know,
to actual previous legislation we now have, you know, clinical
managers which have been hired, high level, with specifically
that job in order to make sure panels are managed properly,
that data is accurate, that in fact there is an understanding
at the front line primary care level in fact that, you know,
there is some, they have some authority over their panels and
they need to be good feedback, and there needs to be this
alignment of leadership at every level. And these, they are
currently being trained. There are training programs that we
have developed in the VA specifically for this. Dr. Stark is
actually one of the major initiators of this.
Dr. Wenstrup. Throughout are they physician driven?
Dr. Schectman. The program is physician led.
Dr. Wenstrup. Okay. That is helpful. But to my other point,
too, you know, there are models within the private sector that
we may be wanting to take a look at that say what is the right
number and are we providing those visits where, you know, hey,
you have diabetes and I do not want to see you when you crash,
I want to see you every four months anyway, you know, and that
type of thing.
Dr. Stark. Yes, the patient centered medical home model or
PACT is really the embodiment of that philosophy. And so we
take that very seriously.
Dr. Wenstrup. And are there tools to evaluate are we
actually saving money by doing that? Because I believe that
overall we do if we are truly a preemptive healthcare facility
as opposed to just treating.
Dr. Stark. Yes. We have looked at that. It is still
preliminary and it is difficult to make those assessments but
as Dr. Lynch mentioned earlier, high performing PACTs have
lower hospital readmission rates and other indicators of better
outcomes that end up costing us less.
Dr. Wenstrup. Well might I suggest that we maybe look at
some of those concierge type services that you actually could
provide I think in the VA, that type of entity that might be
helpful for us in the long run. Thank you. I yield back.
Dr. Benishek. Dr. Huelskamp.
Dr. Huelskamp. Thank you, Mr. Chairman. I appreciate the
subject of the hearing today and the GAO report, which I find
very interesting and very insightful. By my count I think that
is the, this is the 38th report that has documented data
inconsistencies. And by the way, I just made that number up.
But there has been a lot of reports on that. And but the
question I guess for Dr. Lynch or Dr. Stark, I might add,
bluntly, how valid and reliable is the data that we have been
discussing here in your opinion?
Dr. Lynch. I will take a start that I think there have been
some inconsistencies and they have given us some challenges. I
think that the new primary care module that will be looking at
PACTs are going to address some of those inconsistencies,
especially in paneling patients who may have died or who may
not be seeing VA, and maybe looking to give us more accurate
data and allow us to monitor that data. I will let doctor----
Dr. Huelskamp. My question though was validity and
reliability. Could you address each of those separately, of the
data here? The GAO reports vast inaccuracies, but validity and
reliability, can you distinguish between the two for me?
Dr. Lynch. I think we have concurred with the GAO that our
data is not reliable and therefore there may be some lack of
validity. I think however when we look at things at a larger
level we can get some information but we can get better
information and we are working on that.
Dr. Huelskamp. And I appreciate that recognition. Because,
I mean, we have been hearing data back and forth. And if it is
not reliable, I mean, this discussion is really rather
fruitless until we have the reliable data. But is there
punishment for employees who fail to report the data accurately
and who is responsible for, finally at the end of the day, who
at the VA is responsible for the data we are discussing?
Dr. Lynch. The facilities and central office are
responsible for the data. Would I blame an individual? Probably
not so much as our system that has not provided the tools they
need to provide us accurate information, and that is what we
are working on.
Dr. Huelskamp. So who is responsible then? At the end of
the day, when you go back to your office and say they asked me
a lot of questions about data. I admitted it was not reliable
and probably invalid, strike one and two. Who do you call, Dr.
Lynch, and say, okay, fix this problem?
Dr. Lynch. Central office takes ownership for trying to put
that data together, sir. And we are working to provide new
tools to do that.
Dr. Huelskamp. Is there any one person? Or who ultimately,
who do you call? Not central office. I do not know how many
people work in the central office. But who is responsible? Who
is going to fix this, in other words?
Dr. Lynch. There are a number of offices that are
responsible. VHA central office is probably the individual
group that is responsible for getting you the data that you
need, sir.
Dr. Huelskamp. But is there an individual that is in charge
of this data project? Or it is just a committee of folks?
Dr. Lynch. It is a number of people in central office that
are trying to work to solve this problem, sir.
Dr. Huelskamp. And so they are all guilty and all
responsible or all unaccountable? I am just trying to----
Dr. Lynch. I think they are all trying very hard to work
through a system of data. It is put together in a computer
system that was never meant to do what it is supposed to do
today.
Dr. Huelskamp. And you mention----
Dr. Lynch. Our computer system goes back to 1985. Our
system changed significantly in 1995 when we went from
inpatient care to outpatient care, and our systems have not
changed substantially, sir.
Dr. Huelskamp. And we are still determining, here trying to
figure out what is the appropriate panel size, even though we
are not for certain we are even measuring panel size, and we
are not for sure what we--by the way, does an encounter include
a phone call? Is that one encounter? How do you count that?
Dr. Lynch. It can be billed as an encounter, sir, yes.
Dr. Huelskamp. Does an email to a patient, is that an
encounter?
Dr. Lynch. To my knowledge right now an email does not
count as an encounter, is that right, Dr. Stark?
Dr. Stark. If it meets certain criteria for medical
decision making it can be coded as an encounter.
Dr. Huelskamp. Do we know what percentage of the encounters
are, and that is fundamental to the second part of the report
in terms of the vast wide range of cost. So if a phone call and
perhaps an email can be an encounter, do you know how many,
what percentage of encounters actually fit that----
Dr. Stark. About 30 percent of our encounters are by
telephone.
Dr. Huelskamp. And what percent are emails?
Dr. Stark. I do not have that data. That is a relatively
new----
Dr. Huelskamp. Yes, that is only 20 years old. I get that.
I am just kidding, I do not know how long you have been
counting that. But in the private sector, do they count that as
encounters? Just a phone call, a reminder you are going to have
an appointment? Or something like that? Or----
Dr. Stark. Phone calls do count in the private sector. It
is a lesser weight encounter than a face to face visit.
Dr. Huelskamp. Okay. I would like a little more followup
then on the data, breaking that down, what that encounter is.
Because that was critical to the second part of the GAO report,
trying to figure out, we have got this wide range of
expenditures. And just to let you know, the piggy bank is about
empty. So we need to do a better job of how we spend this
money. I yield back, Mr. Chairman.
Dr. Benishek. Mr. Coffman, you are recognized.
Mr. Coffman. Thank you, Mr. Chairman. Well one thing that
is not acknowledged in this report is something that I think
VHA leadership is very good at, is very effective at, without
parallel. And that is your ability to cut bonus checks to each
other. I mean, that is extraordinary in the amount of money
spent on that for whatever reason.
But let me, as someone who is involved in healthcare on the
House side, on the Armed Services side, and on this side, that
when our severely wounded coming out of Iraq and Afghanistan
are handled different than our severely wounded were, coming
out of Vietnam. In Vietnam they were stabilized in the military
system and then they went to the VA for their rehabilitation.
Now we keep, extend them on active duty for their
rehabilitation, unless they specifically request to go to the
VA which is very rarely done. Then they are medically retired
so they are under the TriCare system. So I hope we can improve
the VA to where we feel confident about putting our war wounded
there, but that is certainly not the case today.
What is extraordinary I think about this report, and I
think about the culture of the VA, is that when mediocrity is
legally protected, this is the system you get. The military
system, and I am 21 years in the military, we have a number of
former military officers here, some current, Dr. Wenstrup. But
it is a merit based system. Let me tell you, Dr. Lynch, you
would not survive in the military system. Period. And maybe you
were there at one time, and I know a lot of people in the VA
come from the military, but they have forgotten all the values
that they learned in the military. And let me tell you there
are a lot of good people in the rank and file of the VA, do not
get me wrong. And they are the people that step forward as
whistleblowers that we are trying to protect here on this
committee from retaliation from leaders like yourselves. And so
it is just extraordinarily disappointing that, what we are
seeing today. We need to make the Choice program work. I think
the Choice program will make you better. That the fact I think
you take the veterans of this country for granted. And I think
that having some level of competition will be helpful. And I
think we need at the end of the day to have some system when we
get the Choice program to work that the VA is not very
cooperative in making it work that that demand needs to reflect
if relative demand to the VISN, if people prefer the Choice
program to the VISN then we need to bring down the number of
employees in the VA for that specific VISN. That will come
eventually.
Let me just reference the report. The GAO report indicated
that in its comments, well, to this report, VA did not provide
information on how it plans to address unreliable panel size
data accountability. In response GAO recommended that VA
specifically assign responsibility for verifying each
facility's reported panel size data. Who should have this
responsibility? And when will VA publish its guidance
identifying those individuals? Dr. Lynch.
Dr. Lynch. So that would fall to Dr. Stark and his office.
Mr. Coffman. Okay.
Dr. Lynch. And we are in the process of validating our data
as we implement the new PCMM web system to monitor our panel
sizes. That is part of the process to improve the accuracy of
our data.
Mr. Coffman. And Dr. Lynch, why do you think that the
culture of the VA is what it is today? That why we get the
scandal after scandal after scandal in the VHA system? Why do
we have the wait time system that, where there was manipulation
of the wait time for appointments in order to get cash bonuses?
And that went all the way up, and I believe that the head of
the Phoenix hospital has, I do not think she has been fired
yet, or do you know what the status of that person is? I
understand they are on paid leave, can you speak to that?
Dr. Lynch. I think the former director has been terminated,
sir.
Mr. Coffman. Has been terminated?
Dr. Lynch. Yes.
Mr. Coffman. Okay. Mr. Chairman, I yield back.
Dr. Benishek. Thank you. Ms. Walorski.
Ms. Walorski. Thank you, Mr. Chairman. Dr. Lynch, several
months ago we did a hearing, I do not even know, it could have
even been last year. I do not remember. But we talked about the
issues on the credentialing process for vendors and some of the
confusion that happened around the country with unauthorized
vendors being in different places and that kind of thing. So I
have been working on legislation that I introduced that would
create a uniform framework for enabling the presence of medical
vendors. This is not necessarily a new issue. But as you
examine ways to reduce the administrative burdens and improve
efficiencies in your VMACs, have you considered creating a
standard framework for vendor access? Has that been talked
about?
Dr. Lynch. We have been working following those initial
meetings to come up with a process that allows us to have full
eyes on what is coming into our institution, where it is coming
from, and where it is going. Yes, Congresswoman.
Ms. Walorski. Okay. Are you looking at solutions from the
private sector organizations to help streamline that process?
Dr. Lynch. I was not part of the group. I cannot confirm
that. But I would suspect we have been looking at the private
sector. We have been doing that with increasing frequency now.
Ms. Walorski. And then I would ask you this. I know you are
not directly on it. But are there any things that you have
heard that have come out of any of those meetings where
Congress can be a partner in accomplishing that goal?
Dr. Lynch. I have not heard of any specific asks for
Congress but we certainly keep that in mind.
Ms. Walorski. Okay. And could you at least check on it and
get back to us?
Dr. Lynch. I will.
Ms. Walorski. Okay. I appreciate that. And then I have a
question, a final question, on the independent assessment that
was released a few weeks ago concluded that VHA and the Office
of Information Technology, which I have asked about many times,
are not effectively collaborating, which has hindered VA's
ability to ensure IT investments align with its healthcare
objectives. So who within the VHA is responsible for
coordinating and establishing those objectives between those
two offices?
Dr. Lynch. So right now we have a new head of OI&T, Ms.
Laverne Counsel. I think I can honestly say we have a new
sheriff in town who has----
Ms. Walorski. On IT?
Dr. Lynch. On IT.
Ms. Walorski. Okay.
Dr. Lynch. Who has begun to take an interest in issues such
as collaboration and understanding how the different parts of
the organization can work together. I suspect at this point in
time that the lead for those communications would probably be
Dr. Shulkin, but I suspect it will also move down as the more
specific needs are identified. But there has been a change in
attitude----
Ms. Walorski. And you welcome that change?
Dr. Lynch. Pardon?
Ms. Walorski. And you welcome that change?
Dr. Lynch. I do welcome that change.
Ms. Walorski. And I think there has to be real change and
that there has to be a structural change to be able to enhance
those interagency cooperations because of the fact the GAO
report has talked about this as being a serious issue before. I
have asked many, many times on this committee prior to this new
IT person about, specifically about IT because so much money
has gone into it that has been tax money. There has not been a
whole lot of accountability and transparency and there has not
been a whole lot of interagency cooperation. Also, I would hope
if you could take that message back, I know you are not
specifically directed to, but I would hope that we would see
improvement in those two. And again, so that the end goal is
helping the veteran get the healthcare they were promised. And
with that, Mr. Chairman, I yield back.
Dr. Benishek. Thank you, Ms. Walorski. I want to thank all
of you for being here today to give us your testimony, Mr.
Williamson, Dr. Lynch, Dr. Stark, and Dr. Schectman. I think
you pretty much got the idea that a lot of us are very
frustrated about the rate of change or the pace of change. The
reassurances that you are on it, you know, are all well and
good, Dr. Lynch. And you know, I believe you are sincere. It is
just that at this level here we get very frustrated by the pace
of the actual change. And you know, Mr. Williamson has just put
out the report today, and all of a sudden we find out there has
already been change in the way that they are going to do it.
They are implementing the new software. But we have not really
seen the results of that. So we would like to see----
Dr. Lynch. I think I would say, Mr. Chairman, we welcome
the opportunity to come back and share with you the results
that we, our findings as we implement that software.
Dr. Benishek. Yes. Well, I am hopeful that that will be
soon. So if there are no further questions, you all are
excused. I ask unanimous consent that all members have five
legislative days to revise and extend their remarks and to
include extraneous material. And, without objection, so
ordered. The hearing is now adjourned.
[Whereupon, at 11:17 a.m., the committee was adjourned.]
APPENDIX
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