[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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                     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

                              ----------                              

                       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

                              ----------                              


                       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.]

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