[House Hearing, 115 Congress]
[From the U.S. Government Publishing Office]
MAXIMIZING ACCESS AND RESOURCES: AN EXAMINATION OF VA PRODUCTIVITY AND
EFFICIENCY
=======================================================================
HEARING
BEFORE THE
SUBCOMMITTEE ON HEALTH
OF THE
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED FIFTEENTH CONGRESS
FIRST SESSION
__________
THURSDAY, JULY 13, 2017
__________
Serial No. 115-24
__________
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
DAVID P. ROE, Tennessee, Chairman
GUS M. BILIRAKIS, Florida, Vice- TIM WALZ, Minnesota, Ranking
Chairman Member
MIKE COFFMAN, Colorado MARK TAKANO, California
BRAD R. WENSTRUP, Ohio JULIA BROWNLEY, California
AMATA COLEMAN RADEWAGEN, American ANN M. KUSTER, New Hampshire
Samoa BETO O'ROURKE, Texas
MIKE BOST, Illinois KATHLEEN RICE, New York
BRUCE POLIQUIN, Maine J. LUIS CORREA, California
NEAL DUNN, Florida KILILI SABLAN, Northern Mariana
JODEY ARRINGTON, Texas Islands
JOHN RUTHERFORD, Florida ELIZABETH ESTY, Connecticut
CLAY HIGGINS, Louisiana SCOTT PETERS, California
JACK BERGMAN, Michigan
JIM BANKS, Indiana
JENNIFFER GONZALEZ-COLON, Puerto
Rico
Jon Towers, Staff Director
Ray Kelley, Democratic Staff Director
SUBCOMMITTEE ON HEALTH
BRAD WENSTRUP, Ohio, Chairman
GUS BILIRAKIS, Florida JULIA BROWNLEY, California,
AMATA RADEWAGEN, American Samoa Ranking Member
NEAL DUNN, Florida MARK TAKANO, California
JOHN RUTHERFORD, Florida ANN MCLANE KUSTER, New Hampshire
CLAY HIGGINS, Louisiana BETO O'ROURKE, Texas
JENNIFER GONZALEZ-COLON, Puerto LUIS CORREA, California
Rico
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, July 13, 2017
Page
Maximizing Access And Resources: An Examination Of VA
Productivity And Efficiency.................................... 1
OPENING STATEMENTS
Honorable Brad Wenstrup, Chairman................................ 1
Honorable Julia Brownley, Ranking Member......................... 2
WITNESSES
C. Sharif Ambrose, Principal, Grant Thornton LLP................. 4
Prepared Statement........................................... 21
Randall B. Williamson, Director, Health Care, Government
Accountability Office.......................................... 5
Prepared Statement........................................... 24
Jonathan B. Perlin MD, PhD, President, Clinical Services Group,
Chief Medical Officer, HCA Healthcare, Inc..................... 6
Prepared Statement........................................... 28
Carolyn Clancy M.D., Deputy Under Secretary for Organizational
Excellence, Veterans Health Administration, U.S. Department of
Veterans Affairs............................................... 8
Prepared Statement........................................... 31
Accompanied by:
Murray D. Altose M.D., Chief of Staff, Louis Stokes Cleveland
VA Medical Center, Veterans Integrated Service Network
10, Veterans Health Administration, U.S. Department of
Veterans Affairs
MAXIMIZING ACCESS AND RESOURCES: AN EXAMINATION OF VA PRODUCTIVITY AND
EFFICIENCY
----------
Thursday, July 13, 2017
U.S. House of Representatives,
Committee on Veterans' Affairs,
Subcommittee on Disability Assistance
and Memorial Affairs,
Washington, D.C.
The Subcommittee met, pursuant to notice, at 2:02 p.m., in
Room 334, Cannon House Office Building, Hon. Brad Wenstrup
[Chairman of the Subcommittee] presiding.
Present: Representatives Wenstrup, Bilirakis, Radewagen,
Dunn, Rutherford, Higgins, Brownley, Takano, Kuster, and
Correa.
Also Present: Representative Roe.
OPENING STATEMENT OF BRAD WENSTRUP, CHAIRMAN
Mr. Wenstrup. The Subcommittee will come to order. Good
afternoon and thank you all for joining us for today's hearing,
``Maximizing Access and Resources: An Examination of VA
Productivity and Efficiency.''
Today, we will discuss clinical productivity and efficiency
in the Department of Veterans Affairs' health care system. As a
clinician and a veteran, this is an issue I hold near and dear
to my heart. As one of our witnesses, the Government
Accountability Office, will note this afternoon, VHA's bottom
line has grown significantly over the last decade, increasing
from $37.8 billion in fiscal year 2006 to $91.2 billion in
fiscal year 2016.
As a Federal agency, VA has an obligation to be a
responsible steward of the taxpayer dollars that so generously
fill its coffers. As the Federal agency responsible for
providing health care to our Nation's veterans, VA has an
obligation to be a responsible servant worthy of caring for the
greatest fighting force the world has ever known.
However, it is not clear whether or not the increasing
amount of money that has been allocated to VHA has resulted in
a more productive, efficient health care system or in veteran
care that is more accessible, more high quality, or more cost
effective, and that is our goal.
This afternoon, we are going to examine findings from both
a recent GAO report and from the 2015 independent assessment,
which will detail a variety of concerns with clinical
efficiency and provider productivity at VA medical facilities.
For example, we are going to hear how the current models
and metrics at VHA uses to assess clinical efficiency and
provider productivity failed to account for all providers and
services, failed to accurately reflect the intensity of
clinical workloads and staffing levels, and may be populated
with inaccurate data, as well as how VA central office policies
and procedures failed to provide sufficient monitoring and
oversight, even when problems have been identified.
We will also discuss how VHA's productivity compares to
leading private sector health care systems and what industry
best practices VHA may be able to use to increase quality and
efficiency. For example, we are going to hear that the number
of patients assigned to VHA primary care providers is 12
percent lower than the private sector benchmark for patients of
a similar acuity, which all begs the question, what are we
paying for?
To be clear, VHA is taking strides in making progress, and
not all of the barriers to increased productivity and
efficiency are under the control of the individual VA medical
facilities or providers. As we discussed during yesterday's
Full Committee hearing on VA's capital asset deficiencies, the
average VA medical facility building is five times older than
the average building in a not-for-profit hospital system in the
United States and is not well situated to the provision of high
quality care or to efficient practice of medicine in the 21st
century.
As a doctor myself, I know firsthand the constraints that
are placed on a provider who lacks sufficient clinical space
and adequate support staff. In the private sector, room-to-
provider ratios are typically 3 or 4 to 1. In the VA health
care system, providers typically only have a 1-to-1 room-to-
provider a ratio, as well as significantly fewer nurses and
administrative staff. So that means, in many cases, the deck is
stacked against a VA doctor the second they step into their
clinic.
We need to find solutions for those providers, for the
taxpayers whose hard-earned dollars are supporting VA's massive
bureaucracy in increasing frequency and, most importantly, for
the veterans who deserve a more efficient, accessible VA health
care system.
I will now yield to Ranking Member Brownley for any opening
statement that she may have.
OPENING STATEMENT OF JULIA BROWNLEY, RANKING MEMBER
Ms. Brownley. Thank you, Mr. Chairman.
Paired alongside yesterday's hearing on capital asset
management, the topic of VHA productivity and efficiency is
both timely and vital as we discuss VHA's ability to care for
our Nation's veterans in the future.
Yesterday, former Secretary Principi stated he did not
believe VA would survive another decade of capital asset
constraints on the scale we see now. I could not help but think
of how this issue of provider productivity and efficiency ties
directly into the issues we see with capital asset management
at the VA.
As Ranking Member Walz and Chairman Wenstrup mentioned in
yesterday's hearing, it is crucial that VA be able to
accurately determine the capabilities of its staff when
determining the fitness of its infrastructure. I am concerned
that VHA does not have the tools necessary to make this
determination. Even more concerning is the idea that VHA is
relying on faulty productivity and efficiency data while
shifting significant resources, including taxpayer dollars,
into the community and away from VHA facilities.
It is difficult to believe VHA is confident in its
multibillion dollar budget request for fiscal year 2018 when it
is increasingly evident VHA does not have the tools necessary
to make decisions using proven processes that are based on
sound data. In its report, GAO made many recommendations
similar to those made by Grant Thornton in its 2015 assessment
of VHA's productivity. While VA has concurred with these
recommendations, I am curious as to why they were not addressed
immediately following the assessment by Grant Thornton.
If the same issues are being raised repeatedly by multiple
parties almost 3 years apart from each other, I do not think
VHA can boast of its progress in addressing the issues. I
understand that some of the recommendations made by Grant
Thornton and GAO are difficult, even for the private industry,
to address, but VA has a track record of leading the health
care industry, and I will continue to hold VA to that standard,
the standard of an industry leader.
I am hopeful VHA will take the issues raised during this
hearing seriously, and I hope my colleagues and I are able to
support you as you address these issues in a timely manner.
While the adoption of a new generation electronic health record
system will assist in accurately collecting workload data, VA's
capital asset portfolio will not wait the 8 or 9 years it will
take for VA to set up the new electronic health record system.
Therefore, this new system cannot be the excuse VHA uses to
further delay the implementation of both Grant Thornton's and
GAO's recommendations. During today's hearing, I hope to learn
more about this issue so that I can support VHA in its efforts
to develop an accurate and useful system that promotes the
productivity and efficiency of VHA's health care providers.
Thank you, Mr. Chairman. And I yield back.
Mr. Wenstrup. Thank you, Ms. Brownley.
Unfortunately, at this time--you heard the buzzer--they
have called us over to vote. And I hate when this happens. We
are going to have to go to vote, and I am going to ask you if
you would please stay nearby, and we will come back and
continue on after the vote series that is taking place right
now. And I appreciate your patience on that. Thank you.
[Recess.]
Mr. Wenstrup. Welcome back. I am going to take a liberty,
because we have a time constraint on this room. Before I
introduce you, so I can give you a minute or two to prepare,
rather than 5 minutes for your opening statement, if it is
possible that we could reduce them to 3 minutes, and then we
will have adequate time for questions. If that is okay, I would
like to proceed in that direction.
So joining us on our first and only panel is C. Sharif
Ambrose, principal at Grant Thornton LLP, one of the authors of
The Independent Assessment; Randall B. Williamson, Healthcare
Director from the Government Accountability Office, Dr.
Jonathan Perlin, former Under Secretary for Health and now the
President of Clinical Services and Chief Executive Officer of
Hospital Corporation of America; and Dr. Carolyn Clancy, Deputy
Under Secretary for Health for Organizational Excellence, who
is accompanied by Dr. Murray Altose, the Chief of Staff of the
Louis Stokes Cleveland VA Medical Center. I want to thank you
all for being here.
And, Mr. Ambrose, you got the short straw, I guess. We
would like to begin with you and you are now recognized for 3
minutes. But having you go first, if you are over a little bit
over, I think we will be okay with that. So you are now
recognized.
STATEMENT OF C. SHARIF AMBROSE
Mr. Ambrose. Thank you. And good afternoon, Chairman
Wenstrup, Ranking Member Brownley, and Members of the
Subcommittee. Thank you for the opportunity to discuss Grant
Thornton's 2015 report on VA provider staffing and
productivity. My name is Sharif Ambrose. I am a principal at
Grant Thornton, where I lead our public sector health care
practice, and we provide consulting services to government
clients, including the Department of Veterans Affairs. And it
has been our distinct privilege and honor to support the U.S.
Department of Veterans Affairs and the veterans it serves for
the past 20 years.
I am accompanied by my colleague Erik Shannon, who leads
our commercial health care advisory practice, who also
contributed to this assessment.
CAMH served as the program integrator and as primary
developer of 11 of the Veterans Choice Act independent
assessments. CAMH is a federally funded research and
development center operated by the MITRE Corporation.
We conducted our assessment in 2015 of current provider
staffing levels, caseload, and productivity, and in comparison
with health care industry benchmarks.
Among our findings in assessment G is a couple I would like
to share with the Committee. First, we found that VA doesn't
systematically track fee-based provider productivity and does
not capture the FTE level information for fee-based provider
care providers. We also found that staffing levels per patient
population were in most specialties lower than the industry
ratios. The ratios, however, are not sufficient to establish
whether VHA is staffed to meet demand, because of factors that
make it difficult to measure clinical workload of VHA and to
compare to industry benchmarks.
Further, we found that the number of patients assigned to
VA general primary care providers is 12 percent lower than the
private sector benchmark for patients of a similar acuity. And
with respect to specialty providers, our analysis shows that VA
specialists are less productive than their private sector
counterparts on two measures: encounters and work relative
value units, otherwise known as wRVUs.
We studied root causes, and our team examined many of them
that drive VHA provider productivity and found several factors
that limit the ability of providers to optimize productivity.
First, we found that VA providers have a lower room-to-
patient ratio than their private sector counterparts. Room-to-
provider ratios in the private sector are typically 3 to 1, and
we found that VA providers typically only have a 1-to-1 ratio,
which doesn't allow them to see as many patients as their
private sector counterparts. Similarly, VA providers have
significantly fewer nurses and administrative support staff,
which means the providers can't be as efficient as they
otherwise could be.
We outlined many recommendations in our report. First and
foremost is that we recommended that VA evaluate the design and
implementation of their staffing models, to which they are
sufficient to ensure all eligible veterans have access to high-
quality and timely care.
I think I will yield my time, in the sense of time, to the
other witnesses. Thank you.
[The prepared statement of C. Sharif Ambrose appears in the
Appendix]
Mr. Wenstrup. Thank you. I appreciate that.
Mr. Williamson, you are now recognized.
STATEMENT OF RANDALL B. WILLIAMSON
Mr. Williamson. Thank you, Chairman Wenstrup and Ranking
Member Brownley. VA has developed productivity metrics to
measure physician providers' time and effort to deliver
procedures and methods to track clinical efficiencies at VAMCs.
Using the metrics, VHA's Office of Productivity, Efficiency and
Staffing, or OPES, reports data on each VAMC for VAMCs to use
in identifying suboptimal clinical productivity and efficiency.
GAO's recent study in this area identified limitations with
VHA's metrics and methods that limit VHA's ability to assess
whether resources are being used effectively. Regarding
productivity, there are several needed improvements. First,
while OPES reports provider productivity data for 32 different
clinical specialties, the data only covers VA employed
providers. It excludes contracted providers that work at VAMCs
and others, such as nurse practitioners who are other major
contributors to patient care. Also, VA providers are not always
accurately coding the intensity of their clinical workload,
that is, the amount of effort needed to deliver the procedures
they perform. Finally, VAMC providers may not always be
recording their clinical time accurately.
To its credit, VA has implemented or is developing new
initiatives to improve productivity and efficiency data. For
example, they have intensified training for providers in the
field on proper methods for coding, and they are attempting to
solve other staffing issues as well that relate to labor
mapping.
GAO made recommendations to further improve productivity
and efficiency data, and VHA has concurred with all of them.
Perhaps the most significant issue from our study centers
around VHA's lack of oversight and monitoring to better ensure
that VAMCs with suboptimal productivity and efficiency are held
accountable for making substantive improvements. Currently,
VAMCs with suboptimal productivity are required to develop
remediation plans and submit them to their respective VISNs for
review. However, current VA policy does not require VISNs or
Central Office to monitor VAMCs' implementation and resolution
of these plans.
Moreover, VAMCs are not required to address or monitor
their overall efficiency at all. And as a result, they do not
develop remediation plans to address inefficiencies identified
by OPES data. Our review of data shows that some VAMCs perform
poorly on these metrics year after year, and there appear to be
few real incentives for VAMCs to improve these metrics.
In summary, achieving better productivity and efficiency
will better ensure that VHA is using resources wisely and
maximizing access to health care services for veterans.
Thank you, Mr. Chairman.
[The prepared statement of Randall B. Williams appears in
the Appendix]
Mr. Wenstrup. Thank you very much.
And, Dr. Perlin, you are now recognized for 5 minutes.
STATEMENT OF JONATHAN B. PERLIN, M.D., PH.D.
Dr. Perlin. Thank you, Mr. Chairman, Ranking Member
Brownley, and we thank Chairman Roe and Members of the
Subcommittee for the opportunity to be here today.
HCA is the largest private provider of health care services
with the privilege of about 28 million patient encounters
annually. We have about 241,000 employees, including 8,000
nurses, exclusive of another 37,000 voluntary physicians, and
we have the privilege of seeing patients at 168 hospitals and
1,200 other sites of care. So, roughly speaking, we are
similarly sized to VA.
We also are proud to acknowledge that included in our
dedicated workforce are many veterans and military spouses, and
in the last year alone, we hired more than 5,400 military
veterans and 1,100 military spouses, and that led, in 2015, to
the Chamber of Commerce Foundation's Award for Hiring Our
Heroes, the Lee Anderson Veteran and Military Spouse Employment
Award.
On that basis, on the basis of my history in VA, I believe
that I have a unique perspective to offer on this particular
topic, having served as Under Secretary, Deputy, Chief Quality
Officer, and like Dr. Shulkin in his current and previous
capacity, actually seeing patients in VA.
I note Dr. Shulkin's 100-day briefing at the White House,
where he offered a number of observations that he came to from
a business and clinical perspective, and I will note three that
I believe are directly relevant to GAO's assessment of VA
productivity.
Dr. Shulkin's first diagnosis of risk concerned access. His
comments identified substantial progress overall, including
same-day access for primary and certain specialty services but
also identified remaining opportunities for improvement.
Obviously, increases in provider efficiency are an important
means for creating additional capacity and access.
His second diagnosis of risk concerned prompt payment of
external providers. This is an area in which legislative relief
would be helpful. Consolidation of disparate models for
obtaining services outside of VA and, frankly, comportment with
Medicare or private insurer reimbursement models would
facilitate provider participation and increase veteran access
to services. The complexity of the different VA models imposes
statutory inefficiencies on VA's overall management of care
both within and outside of VA.
The third area noted by Dr. Shulkin was quality, and VA is
to be commended for making their star ratings public. VA is
increasingly benchmarking against private sector, and in many
instances, VA's performance is as good, if not better, and I
note, in particular areas, these areas, because they are
salient to the comments on productivity within GAO.
GAO notes, as Mr. Williamson said, that the productivity
metrics are not complete, and the new information system should
provide a resource for capturing workload. This is a perennial
challenge, as is the attribution to particular providers, and
this is well-demonstrated in the history of attributing
performance metrics around quality and safety.
I would note that in our organization, when we think about
the care of hospitalized patients, rather than trying to
capture every individual action, we summarize by looking at
things like employee equivalents per occupied bed.
GAO also notes that intensity of service may not be
quantified. That is something that is incentivized more in
private sector because it calibrates to a reimbursement.
So, on the basis of my experience with VA management
systems of more than a decade ago and my research for this
particular hearing, I would note that VA's Central Office has
taken steps to help VAMCs monitor provider productivity by
developing tools to oversee performance and efficiency. VA and
HCA share a strategic and operating advantage in that scale,
and within that scale is the capacity to look for not only
negative but also positive variation. If the underpinnings of
better performance can be understood, replicated in scale, it
becomes the means to elevate the performance of the entire
system.
So understanding variation within the system in comparison
with external performance standards is really why both internal
and external benchmarking is necessary. Internal benchmarking
is a tool for learning and management. It can function as an
important control system for facilities, for VISNs, and for
VACO leadership to manage performance.
External benchmarking is necessary to understand whether
internal performance is superior, consistent with, or inferior
to external organizations. External benchmarking is limited by
differences in data availability and data definitions, but I
would note that the biggest challenge to external benchmarking
is not related to data but, rather, certain inherent features
of VA and the patients it served.
First, veterans using VA are systematically more complex
than commercially insured or even mixed commercial-government
patients, and so benchmarks need to be calibrated to that
increased complexity. Second, the VA benefits package is
systematically different than either commercial insurance or
other government programs like Medicare or Medicaid, and there
are many more things that VA providers can, should, and really
must do to care for veterans appropriately.
Indeed, in the capitated system, it is rational to take all
necessary actions for preventive services or other
interventions that reduce the need for future services or
subsequent interventions. Again, there is this tension between
work and recording of work.
Third, our views were developed in fee-for-service
environments and really do calibrate recorded work with
compensation. In point of fact, it is not only about
efficiency, but recording quality. In our organization, we
always look at productivity and compensation together only with
quality, which is the nonnegotiable foundation.
Fourth, in our organization, in our physical plants and, as
you referenced, the Ranking Member referenced in your
statements, the VA physical plant doesn't support multiple exam
rooms, and this compromises the ability for the most efficient
care.
Finally, I would note that, as you noted as well, that
there may not be as many supportive staff. And there are times
when it may be inefficient or inappropriate for VA to produce
all of its care internally. And in this respect, I agree with
the Secretary's perspective to use private sector services when
geographic access, wait times, capacity, demonstrated clinical
performance excellence or technology are not available in VA.
Let me close with the comment that looking at quality is
obligatory. Quality and safety are always the most efficient.
Rework for breaches in either is neither efficient nor
consistent with the performance excellence the taxpayers
deserve and the veterans should expect and certainly have
earned through their service and sacrifice.
Thank you.
[The prepared statement of Jonathan B. Perlin, M.D., Ph.D.,
appears in the Appendix]
Mr. Wenstrup. Thank you. Just under 3 minutes. You barely
made it.
Dr. Clancy, you are now recognized.
STATEMENT OF CAROLYN CLANCY, M.D.
Dr. Clancy. Thank you. Good afternoon, Chairman Wenstrup,
Ranking Member Brownley, other Members. I am very happy to be
here. I am here with Dr. Murray Altose, who is the Chief of
Staff from the Cleveland VA Medical Center.
Let me just reiterate that our top priority is improving
access to care for our veterans, and improving productivity and
efficiency is a means to that end.
As the others have noted, we have developed a pretty
sophisticated tool that is calculated in industry-based
resource: relative value units. And this is used widely across
our system, and we can actually see that by the number of web
hits. We have seen an increase of 37 percent in the past year
in terms of the number of people actually looking at this.
Getting to optimal productivity and efficiency is, by
definition, a team sport, where deployment of providers is
continuously evaluated and revised, and there is a very strong
collaboration between the clinical workforce and the
administrative function.
As others have noted, we implemented clinical productivity
metrics in 2013 and have developed statistical models to track
efficiency at our medical centers. We have designed reports to
provide our leaders and facilities and networks with essential
tools to understand which clinics are working under, at, or
over capacity, and we have something called the SPARQ tool that
I know you have seen, Mr. Chairman, which actually gives our
leaders a sense of whether clinics are working under, at, or
over capacity.
Since the tool's introduction, as I noted, we have measured
reportable progress, as demonstrated by increase in RVUs. Our
system-wide focus on improving access to care, prioritizing
urgent clinical needs, and achieving same-day access for
veterans with urgent primary care or mental health needs has
resulted in a 13-percent increase in clinical workload, with a
concurrent increase in RVUs for a clinical employee of 9
percent.
Specialty practices that are not meeting productivity
aren't required to develop remediation plans. And, in fact,
there is a monthly meeting between clinical operational
leadership at Central Office with the network with those who
are reported as outliers, using statistical trigger tools.
We have concurred with the GAO recommendations and are
already working to complete them. I want to make note and
really recognize my colleagues who developed data to assess the
clinical productivity of advanced practice providers several
years ago. In most of health care, the work of those providers
has been subsumed under the billing done by the clinicians,
physicians with whom they work. So we will be setting
performance standards for those providers in the very near
future and I believe may become actually the reference for
other systems, because of expanding full practice authority.
Thanks to the Congress, the group practice managers that we
have at all of our facilities now overseeing staff and clinic
flow I think has been one of the most exciting developments in
our system. They are charged with specialty practice management
and have quickly and adroitly begun addressing the myriad
issues in optimizing clinical practice in realtime. Our best
facilities--Cleveland would be one--have established a regular
rhythm, with close collaboration between the group practice
management, the chiefs of staff, the service chiefs and so
forth, and they are constantly conferring about how to do
better.
And, with that, I think I will simply conclude my remarks.
We find the GAO's recommendations helpful. We have made
progress and will continue to move in that direction.
[The prepared statement of Carolyn Clancy, M.D., appears in
the Appendix]
Mr. Wenstrup. Well, I thank you all, and I am going to take
some 5 minutes for questioning. I appreciate you all being
here.
I can tell you a lot of the ideas that I hear coming out of
today are greatly appreciated, but, to be honest with you,
there are a lot of ideas that I and other Members of this
Committee have been talking about and asking to be implemented
since I have been here, which is 5 years, 2013.
For example, with metrics, and even as of this week, when I
asked about being able to measure RVUs, I am told, well, we
don't have them for everybody. And today we heard that
contractors are excluded. This is not the way to really, in my
mind, develop some understanding of what is taking place. If we
set up metrics, we should be able to set up metrics to evaluate
the VA health care system in general, each VISN, each hospital,
each facility, CBOC, each practitioner, for that matter. And it
is a matter of simply training people to know how to code.
And what my first question is, are our providers not able
to code the way that private practitioners do so that we can
track RVUs? It is a relatively simple system if you know how to
bill and how to code what you have done. Is that missing from
our health care system in the VA?
Dr. Clancy. Many of our providers are quite good at it. I
would almost expect certainly that they are less good at it
than private sector providers, because they don't have the same
direct billing incentive, and we don't have the same number of
expert coders on the ground locally.
So, with that caveat, some are better than others, and we
are committed to training those who are having more trouble.
Mr. Wenstrup. Across the board, contractors and everything?
Dr. Clancy. Contractors we have a little more trouble with,
because the nature of our contract is that we are not paying
for their time. We are paying for the services they produce on
a fee-for-service basis. So we are not actually hiring someone
to work a full day in the clinic or half a day.
Mr. Wenstrup. Well, then if they are on a fee-for-service
basis, they know how to code.
Dr. Clancy. Yes, exactly.
Mr. Wenstrup. So they don't need the training.
Dr. Clancy. Exactly.
Mr. Wenstrup. They already got it.
So you mentioned, Dr. Clancy, that those that are
suboptimal, they have to present a plan. How can they present a
plan if they don't know what they don't know? It seems to me
that a plan should be delivered to them. Someone should be
assessing their clinic and say: Hey, you know what, this 1-to-1
ratio doesn't work. Maybe they don't know that if that is all
they have ever seen. Why are they developing the plan when they
are already operating a system that is doing wrong? I would
love to have their advice on how they can get it better, but
why are we waiting for them to develop a plan? Shouldn't we be
giving them the plan?
You know, we would do that in our own practice. If one is
producing more than the other--and we are always concerned
about quality; you got to concede that for sure--but, hey, this
doctor has two medical assistants; you only have one; and they
are seeing twice as many patients and delivering the same
quality. So the plan needs to probably come from someone else
who has had some success.
Dr. Clancy. Well, the plans have to be signed off on by
their service chief. So this is not just asking someone who is
doing a bad job to tell me how can you do better, okay?
Secondly, as I think you are aware, many of our
facilities--and you referenced this in your opening remarks--
are very much space-constrained. Having three or four rooms to
work with feels like, you know, something from Star Wars. But
most--
Mr. Wenstrup. My question comes into really, or my concern
is, who is providing the guidance in creating the plan so that
they are more productive? That I think we have to talk about,
because you said that they submit their own plan. Well, they
are not the experts, obviously, if they are suboptimal. You
need someone who knows how to be optimal to create the plan, in
my opinion.
Dr. Clancy. The guidance is two parts: One is technical in
terms of what do these trigger tool means and what do your
metrics actually mean, so that they can understand the delta
that we are seeing, particularly if they are not actually all
that familiar with it. But the real guidance is operational
leadership, and I might just ask Dr. Altose to chime in on
that.
Dr. Altose. So I would offer that the agenda that is
offered to the facilities by Central Office I think is
reasonable. The priorities are set. The resources are
distributed. The oversight does take place.
The big issue, in my opinion, is simply operations at the
local level. And it is complicated because, as has been pointed
out in much of this testimony, there are many parties who
contribute to the provision of care, both on an ambulatory
basis and in the hospital.
Mr. Wenstrup. So this leads to my next question, when you
talk about incentives. I have not been made aware of incentives
for quality and productivity that are measured that are there.
And you said you are working on that. I would like to hear some
of your ideas, and that is my last question before we move on.
Dr. Altose. I can also speak to that and point out that,
particularly in an ambulatory setting, efficiency and
productivity is based on a team effort that involves
schedulers, clerks, providers, nurses, technologists. And each
and every one of those parties need to be able to contribute,
and one aspect lacking is going to seriously compromise
efficiency and productivity.
Reward needs to be offered not to individuals but to teams.
This is a team effort. It requires an effective team, and
rewards need to be distributed to the team, not necessarily to
any one individual.
Mr. Wenstrup. I would agree with that.
Ms. Brownley, you are now recognized for 5 minutes.
Ms. Brownley. Thank you, Mr. Chairman.
I wanted to go back to my opening comments that I made. And
this question is for Dr. Clancy. And I mentioned in my opening
comments about, in the current GAO report, they have made many
recommendations that are similar to the Grant Thornton report
that took place in 2015. The VA concurred with those
recommendations at that time. So I am curious as to why we are
now in 2017, that was 2015 why haven't we met those
recommendations of which you said at that time, I believe, that
you concurred and would work towards? And now you are saying
you are going to work towards the GAO recommendations as well.
So is it a lack of budget, tools, what?
Dr. Clancy. I think one of the biggest critical gaps for us
has been getting the right people into key leadership
positions. I mean, at our best facilities, this culture and
strong sense of it is a team sport starts from the top. And it
was one of Dr. Shulkin's, when he was Under Secretary, top
priorities was to make sure that we filled critical gaps in
leadership across our system.
Some of those are only recently filled, but we are in so
much better shape since he started at VHA. And with our system,
that took time to get the right people into their seats.
Meanwhile, at every level, we are seeing much more attention to
the technical tools.
So the two game-changers, I believe, are the full practice
authority for advanced practice nurses. And, also, we have
already got the tools to know how much they are contributing in
terms of RVUs. And the second is the group practice managers.
Now, getting that practice up and all those slots filled I
would say has taken over a year, but we are now at full or very
close to 100 percent capacity there. They have been trained in
what is essentially a new role in our system and one that I
think is very, very important.
That is why I was expressing our appreciation to the
Congress for insisting on this, because trying to figure out
exactly what this person was, how they would fit in the
existing system did take some time, and it took some training
for them to understand how they would be doing their jobs. But
I think that we are beginning to see the benefits of that now.
Ms. Brownley. Thank you. And I also wanted to follow up
with you on--I think in your testimony back in May of 2016, the
VHA's Health Information Management Program Office developed
and implemented training for providers to improve coding
accuracy. So have all the providers now received this training?
Dr. Clancy. They have certainly all been offered. I would
take it for the record to tell you exactly what proportion. As
you know, in our system, we have some regular turnover among
providers, but we are committed to reaching those, A, who
haven't been trained or have somehow missed the opportunity
and, B, are not doing so well. That is going to be our first
priority focus rather than a blanket across the board for
people who are already doing a good job.
Ms. Brownley. So, just so I understand, so the people who
have been on board and have not--you talked about the churn and
I get that, that piece of it. But are you talking about just
the churn not having been trained or still others in the
organization that have not been trained?
Dr. Clancy. Well, in some of our organizations, we have
people who are effectively working part-time, because they have
got split appointments with academic affiliates. They may have
teaching responsibilities and so forth, which is also another
factor in considering how our productivity stacks up against
the private sector. Do they have those same missions or not?
I wouldn't be shocked to know that some of them may have
not taken full advantage of the opportunity to be trained, and
we will be making sure that everyone gets it.
Ms. Brownley. And then, once a provider has been trained,
then how are you holding them accountable?
Dr. Clancy. Again, this is a regular review, and we are
reviewing centrally, in terms of who are the outliers. Right
now, for example, our best estimate--or at the end of 2016--was
that 14 percent of our specialty practices are under capacity,
working under capacity in terms of productivity.
And then there is a question of diagnosis. Is it that the
physicians are not doing their best work, or is it, as in one
place I visited, that there are no schedulers--there are almost
no schedulers to schedule patients for them to see, which
obviously would be a problem--and so forth? So that is how we
are putting this all together.
Ms. Brownley. Thank you.
And may I have another minute?
For HCA, in your testimony, you state that accurately
capturing the workload of providers who are managing the care
of hospitalized patients is difficult, even in the private
sector. In order to mitigate the administrative burden of
providers, you recommend that workload be captured as a
byproduct of work.
And I guess my question is, is there a system in the
private sector that the VA could look to or purchase off the
shelf that would achieve the sort of accurate capture of this
information?
Dr. Perlin. Thanks, Congresswoman.
That is a terrific question. The systems, the electronic
health records used in the private sector are really optimized
for the coding efficiency. In point of fact, it takes much of
the burden for coding off the provider and allows, frankly,
less expensive, more efficient people to code behind the scenes
so that the provider is taking care of patients and the coders
are coding. So I think there is a workflow issue that could be
used in the near term.
In the longer term, recognizing the Chairman's comment that
he didn't want to wait until the full re-platforming, as VA
does re-platform, I suspect that that system will have many of
those tracers embedded so that workflow can be and captured as
a byproduct of work rather than counterproductive additional
work.
Ms. Brownley. Thank you.
I yield back.
Mr. Wenstrup. Dr. Dunn, you are now recognized for 5
minutes.
Mr. Dunn. Thank you, Mr. Chairman.
I want to note that this particular topic, productivity,
efficiency, quality, these determine value, and this very
subject is going to occupy the attention of this Committee and
I think the larger Committee, as it has for years. It is going
to be a real focus going forward, and we are going to try to
finally find the light on this subject, I hope. And I am
grateful, by the way, to have such an august group of
consultants that we can ask for input on this difficult
subject.
Mr. Ambrose, your findings, between the productivity of
private practitioners and the VHA were intriguing. They are
able to measure productivity with the cost of deliverables, and
the cost of delivering, like the cost of delivering an office
visit, surgery, drugs and so on. You agree that this is a
rational and effective way to measure productivity?
Mr. Ambrose. Well, thank you for the question, Congressman.
If I understood your question correctly, cost is certainly a
component, both at the episodic level as well as the patient
level that should be looked at. And I believe VA has the
ability to measure cost, just like other provider systems do.
We did not in our study--
Mr. Dunn. I noticed you didn't, but I was hoping that that
was the next thing. I read your study.
Mr. Ambrose. Yes. So we did not have a discussion nor did
we analyze that data.
Mr. Dunn. Do you think there is a way we can get to that
data, quickly, easily?
Mr. Ambrose. Well, I believe VA has a cost accounting
system that assigns costs to encounters for patients and by
provider. So I do believe that there is a way to analyze that
data.
Mr. Dunn. I was thinking of you, in your role as an
auditor, would you just take that data or would you--you would
be auditing that, right?
Mr. Ambrose. Well, I think the way we normally approach
things is we look at data, but then we also look at it in the
context of--
Mr. Dunn. How it is gathered.
Mr. Ambrose [continued]. --the environment. We talk to the
physicians, the management, to understand what the data
represents, how it is collected, to make sure that we are
able--
Mr. Dunn. Because we are so short on time, I am going to
cut you off. But I want to say that the cost of deliverables is
a number that is important, I think. It is important to me, and
I think it is important to the VA as well.
Dr. Perlin, you highlighted that some of the biggest
challenges the VA faces are with external benchmarking, and I
thank you also for your testimony. And I would be remiss if I
didn't slip a kudos in for you for my partner--Mr. Poliquin,
the Member from Maine who usually sits on my right side.
The comment on prompt payment of external providers is of
concern and would be something where legislative relief would
be helpful. Do you have a quick answer on legislative relief
that you would recommend for that?
Dr. Perlin. Thank you very much for that question. Right
now, the VA is grappling with eight, as I understand it,
different payment mechanisms for care outside of the VA. As
well, it is really administered as a benefits program, not a
reimbursement program, as most of the transactions are, whether
they are with Medicaid and other governmental payers or whether
they are with commercial insurance.
So giving VA the tools to actually work more in that domain
would be inherently more efficient and would allow that
interaction to be much more seamless, and I believe as a
derivative of that would--
Mr. Dunn. I would love to hear your comments offline
perhaps separately about what we can do to really relieve that
problem, because we are all anxious to relieve that problem,
along with many others.
You also said that there are times when it is inefficient
or inappropriate for the VA to internally produce all the care
veterans need, whether for geographic, wait times, capacity, or
demonstrated clinical performance excellence or technology that
just wasn't available in the local VA. Does this sound like the
Choice Program to you?
Dr. Perlin. I think those are elements of the Choice
Program, but really, those are the Secretary's words that
relate to the reasons to get care outside. No health system can
be all things to all people perfectly in all places. VA is
remarkable in terms of caring for incredibly complex vulnerable
patients. It provides glue and continuity, but certain services
clearly would be more efficient in other environments.
Mr. Dunn. Thank you. As it relates to the external
benchmarking--I love that part of your testimony--you said it
is obligatory to look at productivity and quality
simultaneously. And I would like that also, you know, the
external benchmarking to be kind of marched over to that area
as well, because I have worked in VAs and HCAs, and I see
differences.
Mr. Chairman, I yield back. Thank you.
Mr. Wenstrup. Mr. Takano, you are now recognized.
Mr. Takano. Thank you, Mr. Chairman.
I have a question for the GAO. The GAO's report highlighted
the VA Central Office that the VA Central Office does not
require the VA Medical Centers to monitor efficiency models or
to address inefficiencies identified by them. It only
encourages them to do so.
Mr. Williamson, can you talk a bit about the challenges
that this creates?
Dr. Perlin. Sure. Oversight and accountability seem to be
endemic in VA for a lot of areas. This is certainly one of
them. We have OPES reports, data on efficiency, for example,
and VAMCs basically, at least the ones we visited are basically
ignoring that, because there is no incentive for them. Nobody
is held accountable to provide any remediation plans. It is
data that is out there, and those facilities that take it
seriously probably do something. But, again, there is a raft of
data that OPES puts out there, and a lot of the VAMCs don't
have the capability, the technical capability, or the capacity
to do that.
But incentivizing it--a good example is the SAIL data,
which you are familiar with. There is a star rating system.
There are five things that are measured, in terms of quality,
access, patient satisfaction, productivity and efficiency.
Productivity and efficiency are excluded from that star rating,
so they are not part of that data. The data is there, and it is
recorded, but it is not--and that star rating system is, in
part, used for performance pay for the leadership of each VAMC.
So it is a serious problem.
Mr. Takano. The VA does have--the Central Office does have
the authority--well, that is my question. It has the authority
to go further than encouraging them? Does it have the authority
to mandate it or to direct them to do that?
Dr. Perlin. They have that authority. I would hope that
Deputy Under Secretary for Health for Operations has that
authority. And I think that, in Dr. Clancy's testimony, that
she indicated they are going to take more of a role in that.
But I would like to see that.
Mr. Takano. The GAO also observed that the Central Office
does not have a systemic process in place to monitor these
efforts, that the medical centers and the VISNs are not
required to submit remediation plans to the Central Office, nor
does the policy state that VISNs or the Central Office must
monitor the implementation of the remediation plans.
In your opinion, without direct oversight from the VA
Central Office, are best practices being identified, actually?
Dr. Perlin. I don't think so. I think it could be better
because, without some kind of clearinghouse beyond the VISN
level that allows you to share best practices, it is very
difficult.
And, you know, VA talks about weekly meetings and monthly
meetings where they talk about these things, but a lot of times
those may not be well attended. There is no assurance that
those best practices are out there. It probably needs to be a
little more formalized, in my opinion.
Mr. Takano. All right. Well, I am kind of interested to see
this amazing sort of relationship between the Central Office
and the medical centers. I am kind of surprised myself to learn
this.
But I yield back. Mr. Chairman.
Mr. Wenstrup. Mr. Bilirakis, you are now recognized.
Mr. Bilirakis. Thank you, Mr. Chairman. I appreciate it
very much.
And thank you to the panel for your testimony as well.
A lot of my questions were already answered, but, Dr.
Clancy, you testified that the VA is in the midst of developing
standards for advanced practice providers. When can you expect
those standards to be released?
Dr. Clancy. I believe we have committed to it later this
year. I want to just emphasize that this is an area where we
don't have external benchmarks to refer to very easily because
historically the work of physician assistants, advanced
practice nurses, and so forth has been subsumed under the
billing by physician. So we can't easily turn to another large
system and say, what are the standards? So, to some extent, we
will be, I think, as the Ranking Member noted earlier, in the
lead on this particular area and may end up being a reference
for others.
Mr. Bilirakis. Can you please follow up with that with me?
I would appreciate that.
Let me ask a question, Dr. Perlin, with regard to medical
scribes. You are familiar, obviously, with medical scribes. Are
you using medical scribes within the HCA system?
Dr. Perlin. We have scribes in certain environments. It is
not consistent, but it is part of certain practices.
Mr. Bilirakis. Would you recommend that they be used within
the VA? Now, I know to a certain extent--I want to ask this
question to the VA too. Are we using medical scribes within the
VA, and to what extent?
Dr. Clancy. I know we are using them in some facilities. I
would have to get back to you with a more robust answer in
terms of--
Mr. Bilirakis. Why wouldn't be they be widespread in the
system? I know there are several advantages to that. Are there
any drawbacks? Why don't we have them in place within the
entire system? And I want you to elaborate also, Dr. Perlin, on
what the use, how beneficial they are.
Dr. Perlin. Let me maybe start by providing context. They
sometimes relieve the physician or other provider of the burden
of entering the information. It is an individual choice. There
are providers who are very proficient with electronic health
records, myself included, for whom it actually it would be an
inefficiency in terms of working through someone else.
The other inefficiency that they can offer is that one of
the best parts of electronic records is that they can provide
decision support, and that decision support is kind of hard to
intermediate by someone who tells you: Oh, we got this warning
for this.
So there may be circumstances where efficiency can be
increased, certainly for some surgical specialties where
someone can serve that function as well. There may be
situations in which advanced practitioners who accompany those
surgeons or other providers may add that efficiency.
But I think the broader question, the one you are getting
at that I think is so important, is, how do you just increase
the efficiency of both the individual provider as well as the
overall team?
Mr. Bilirakis. Right. Dr. Clancy, again, if a physician
within the VA requests a scribe, are they readily available,
and why not, if they are not available?
Dr. Clancy. So I would agree with Dr. Perlin that scribes
are one very specific and very helpful tool for increasing
efficiency. In other cases, there is a whole lot of else that
we could be doing in a practice.
In one of our networks, the network that includes most of
Pennsylvania, they have recently begun using scribes and have
seen dramatic increases in efficiency and are actually going to
be bringing their lessons learned back to share with others.
In one recent thing that we did--and I have to look at the
other Chairman for a moment--recently was to actually go
through our view alerts and figure out how could we get rid of
some of those that are actually a huge distraction and
preventing physicians from seeing the most important messages.
And as a result of this system-wide effort, we were actually
able to give back about an hour and a half a week to primary
care physicians, which, again, is another increase in
efficiency and, frankly, decrease in sort of irritation, if you
will.
So I would be happy to make sure that we get you better
information on how the scribes are used. I think, as Dr. Perlin
said, it is often an individual choice and may be competing
with resources for other types of support for the team and the
practice.
Do you use them at Cleveland?
Dr. Altose. No. Very, very little. There is very little use
in Cleveland of scribes. The providers will record it on the
electronic medical record. And we extensively use voice
recognition software so that reports can be dictated by the
providers.
Mr. Bilirakis. Thank you very much.
I yield back. Mr. Chairman.
Mr. Wenstrup. I am going to indulge Chairman Roe. If we
may, we will have one more round of questions--time with Mr.
Correa will be recognized. But I know this room is going to be
occupied shortly.
Mr. Roe. It will be quick.
Mr. Wenstrup. It will be quick. Mr. Correa, you are now
recognized.
Mr. Correa. Dr. Roe, if you would like to go, go ahead,
sir. You said ``quick''?
Mr. Roe. You go ahead.
Mr. Correa. Please.
Mr. Roe. I think Dr. Wenstrup and others, and Dr. Dunn,
those who have practiced medicine for a long time have seen a
lot of the joy leave medicine, and most it is checking boxes. I
call that polyboxia, where you just check all these boxes. And
if you check the right boxes, you are a good doctor; and if you
don't, you are a bad doctor, no matter how your patient
actually ends up. It is a great source of frustration, both
inside the VA--and you mentioned, Dr. Clancy, the number of
prompts that my friends who are at the VA, sometimes 200 a day.
That is so distracting; you can't possibly practice if you are
doing that.
I think that we are going to see the use of medical scribes
more and more, and certainly, in some places, they can be very
efficient. I talked to a group of ophthalmologists in a
community not too far from mine where there were five of them.
They all use one or two scribes. Five doctors see 55,000
patients a year.
And I know that when we put an electronic health record in
our office, it slowed me down. I saw less patients and extended
my day. That was really wonderful. And I couldn't tell much
benefit. I think it has gotten better. I think the EHRs have
gotten better.
But certainly, at the VA, and I have heard Dr. Wenstrup say
this many, many times about, if we only saw as few patients as
most primary care doctors do at the VA, we could just lock the
door and leave, because you couldn't pay your bills. And in
private practice, that is the case. I believe I am right. And
that is what he has tried to get out about how much does it
cost you to actually see a patient at the VA? And, quite
frankly, it is hard for anybody to quantify that, but we could
pretty much tell you in our practice, because at the end of the
year, if we paid our bills, how much I got paid. That is not
the case at the VA.
So we have a bill and Dr. Wenstrup and I have this bill we
are going to mark up on Monday I think it is that is going to
get a pilot program for scribes. I will tell you, in all of the
studies I have read--and I have read several of them--in
urology, general surgery, and others, where they have to see a
lot of patients in a day, it has made their practice more
enjoyable, and it has made it more efficient. And they have
actually done a better job of coding than the doctors do. I did
a lousy job of it. I know I did. I didn't like it, and so I
didn't do a very good job of it.
I think the other thing that you will be able to do is,
with this, with better data going in, I think you are going to
be able to better manage populations and get better patient
outcomes. I really think you will be able to do that.
And is the VA willing to go ahead--I guess I will ask Dr.
Clancy this--if we pass this bill and it gets through the
Senate, implement a scribe program? And hopefully in the next
year or so, we will have an answer, because it shouldn't be
hard to get these people hired.
Dr. Clancy. Absolutely. And, you know, frankly, building on
what we have already started to see in Pennsylvania, I think it
would be terrific.
Mr. Roe. I will yield back.
Mr. Wenstrup. Mr. Correa, you are now recognized.
Mr. Correa. Thank you, Mr. Chairman.
A general question to the panel. As we rush to transform
the VA better, leaner, more responsive, we talk about terms
such as productivity, efficiency, quality, looking at off-the-
shelf systems to try to integrate them. A question to each and
every one of you is: System integration, information systems,
as we look at the Kaisers of the world and we look at the
private sector--a big challenge in the private sector, of
course, is those information systems are not integrated so the
information here does not flow to here, so on and so forth.
What attention, what are you doing to assure that the VA
itself, as you transform it to something better, whatever that
may mean, is fully integrated to be responsive to the needs of
the patient?
Dr. Clancy. So I think you have--Congressman, it is a great
question and you have put your finger on two very, very
important issues.
A third game-changer I believe for access and for being
responsive to patients is telehealth. Now, we use this a lot in
very different ways. We use it for everything from virtual
visits to good old-fashioned telephone visits to video
encounters with specialists and so forth. And ultimately, I
think that we will be doing this in patients' homes. And we do
that in some States right now. How much nicer for a patient
with PTSD to get his counseling and therapy from his own home
rather than driving 3, 3-1/2 hours to the nearest medical
center and so forth. And that has been very, very successful.
Historically, at VA, it has been really wonderful but sort
of separate from all of our other systems. And increasingly in
the past year, year and a half, we have been integrating that
with all of our efforts to make sure that we address our top
priority of access to care.
So I think that is going to be a game-changer, because in
addition to making it much better and much more responsive to
what veterans need and want--I mean, navigating our system or
any health system is not a joy unto itself--it is also a
terrific platform to extend the expertise of specialists, who
tend to be at some of our larger, more complex medical centers,
out to the outlying community-based outpatient clinics and so
forth.
Mr. Correa. If I may follow up, what are you doing to make
sure that, as you come out with this productivity tool that
will multiply your ability to reach out at these, you know,
people that live out in areas that are difficult for them to
come to the VA, what are we doing to make sure that they
understand that this is something that is good and not just a
cost-cutting measure and, therefore, maybe they may think,
patients may think that you are sacrificing efficiency for cost
savings? Are we following with some surveys, with some actual
studies to make sure that, in the process to deliver these
services, quality is not being sacrificed?
Dr. Clancy. Yes. We are actually surveying veterans to see
how well this works for them. In fact, a big fundamental
linchpin of our same-day access for urgent mental health or
primary care needs has been that that may be a face-to-face
visit, it may be a virtual visit, or a phone call, or some
other way that we are helping you resolve your problem today.
But the point is we are not going to be forcing this on people
who don't want it. But, by and large, I would say industry
experience has been that people for the most part really like
it a great deal. So you see the Kaisers of the world doing more
and more of it.
Mr. Correa. Thank you very much.
I yield the remainder of my time.
Mr. Wenstrup. As you can tell by the crowd outside, our
rent is due and the new tenants are ready to move in. So we are
going to have to conclude, and I would encourage anyone, if
they have any further questions, to please submit them for the
record.
So, at this time, the panel is now excused.
And I ask unanimous consent that all Members have 5
legislative days to revise and extend remarks and include
extraneous material.
Without objection, so ordered.
And the hearing is now adjourned, and I thank you all for
being with us today.
[Whereupon, at 4:28 p.m., the Subcommittee was adjourned.]
A P P E N D I X
----------
Prepared Statement of C. Sharif Ambrose
Good afternoon Chairman Wenstrup, Ranking Member Brownley, and
members of the Subcommittee. Thank you for the opportunity to discuss
Grant Thornton's 2015 findings and analyses that focused on VA Provider
Staffing and Productivity. My name is Sharif Ambrose and I am a
Principal at Grant Thornton LLP where I lead our Public Sector
Healthcare Practice that provides contracted consulting services to
government clients, including the U.S. Department of Veterans Affairs.
I am accompanied by Erik Shannon, a fellow Partner at Grant Thornton
who leads our commercial healthcare advisory practice and who also
contributed to the 2015 Independent Assessment.
Grant Thornton is one of the largest professional services firms in
the world and we provide our clients across all major industries with
advice on strategic, operational, financial, and technology issues to
help them achieve their missions. Our health care practioners serve
commercial and government health providers, health plans, and life
sciences clients to create, protect, and transform value across their
organization. It has been our distinct privilege and honor to support
the U.S. Department of Veterans Affairs (VA) and the Veterans it serves
for the past 20 years.
Grant Thornton's involvement in this assessment began after
Congress enacted and President Obama signed into law the Veterans
Access, Choice, and Accountability Act of 2014 (Public Law 113-146)
(``Veterans Choice Act''). \1\ This law was intended to improve access
to timely, high-quality health care for Veterans. Under Title II -
``Health Care Administrative Matters,'' Section 201 called for an
Independent Assessment of 12 areas of VA's health care delivery systems
and management processes.
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\1\ This law was later amended by the Department of Veterans
Affairs (VA) Expiring Authorities Act of 2014 (Public Law 113-175).
---------------------------------------------------------------------------
VA engaged the Centers for Medicare & Medicaid Services (CMS)
Alliance to Modernize Healthcare (CAMH) to serve as the program
integrator and as primary developer of 11 of the Veterans Choice Act
independent assessments. CAMH is a federally funded research and
development center (FFRDC) operated by The MITRE Corporation, a not-
for-profit company chartered to work in the public interest. CAMH
subcontracted with 3 firms with technical and industry expertise -
Grant Thornton, McKinsey & Company, and the RAND Corporation - to
conduct 10 independent assessments as specified in Section 201, with
CAMH conducting the 11th assessment. Part G of Section 201 required an
independent assessment of ``the staffing level at each medical facility
of the Department and the productivity of each health care provider at
such medical facility, compared with health care industry performance
metrics.''
To address this requirement under Part G, Grant Thornton conducted
an assessment during the winter and spring of 2015 of current provider
staffing levels, caseload, and productivity, in comparison to health
care industry benchmarks. This included an in-depth assessment of nurse
staff resource allocation, decision-making, and processes which impact
provider productivity and efficiency.
Our team interviewed VHA policy leaders and subject
matter experts from the major specialties as well as the leaders of the
program offices responsible for reporting VHA staffing levels and
provider productivity.
We obtained staffing, workload, and time allocation data
of VHA providers from VHA for fiscal year 2014.
In coordination with other Choice Act independent
assessment teams, we visited 24 VA Medical Centers and community-based
outpatient clinics (CBOCs). The purpose of the site visits was to
interview local facility leaders and providers to understand the local
management practices, staffing, caseload and productivity levels across
VA.
Our report, along with the other independent assessments, were
provided to the Secretary for Veterans Affairs, the House Committee on
Veterans' Affairs, the Senate Committee on Veterans' Affairs, and the
Commission on Care in September 2015.
Provider Staffing Findings
Grant Thornton's assessment found VA medical centers face issues
with provider vacancies, lengthy hiring processes, and competitive
compensation, each of which can contribute to provider shortages.
Assessment G noted three primary findings.
Finding 1: VHA specialties with the highest provider full-time
equivalent (FTE) levels include medicine specialties, mental health,
and primary care, consistent with VHA's care model and the needs of the
Veteran population.
Finding 2: VHA does not systematically track fee-based provider
productivity, and does not capture FTE level information for fee-based
care providers.
Finding 3: VHA physician staffing levels per patient population
are, in most specialties, lower than industry ratios. These ratios,
however, are not sufficient to establish whether VHA is staffed to meet
demand because of factors that make it difficult to measure clinical
workload at VHA and to compare VHA performance to industry benchmarks.
For instance, VHA uses Advanced Practice Providers (APPs) extensively
but the FTE for these types of providers are not included in VA's data.
Provider Productivity Findings
In comparing VHA providers to providers in the private sector, our
assessment used several common health care industry productivity
measures:
encounters (count of direct provider-patient interactions
in which the provider diagnoses, evaluates, or treats the patient's
condition),
work relative value units (wRVUs-a measure of a
provider's output which takes into account the relative amount of time,
skill, and intensity required to complete a given procedure), and
primary care panel size (the number of unique patients
for whom a care team is responsible).
Our team considered VHA's care model, benchmarked providers
accordingly, and considered the barriers VHA faces in delivering care
at a rate of productivity that matches health care systems in the
private sector. In comparing the productivity of VHA providers to
industry benchmarks, our analysis supports two key findings:
1)The number of patients assigned to VHA general primary care
providers is 12 percent lower than the private sector benchmark for
patients of a similar acuity.
2)With respect to specialty providers, our analysis shows that VHA
specialists are less productive than their private sector counterparts
on two industry measures - encounters and work relative value units
(wRVUs). Many specialties fall in the 50th percentile of private sector
providers; others are as low as the 25th percentile. However, when
encounters (visits) are used as a measure, the gap shrinks and VHA
specialty care compares more favorably to the private sector. In a
system as large and varied as VHA, we did find variation in the
relative productivity of providers. For instance, specialty care
providers at the most complex facilities were found to be more
productive than their peers, and the most productive VHA providers
(those at the 75th percentile of VHA providers) are often more
productive than the private sector. Mental health provider productivity
at VHA was calculated to be in the 100th and 72nd percentiles as
measured by both wRVUs and encounters, compared to industry benchmarks.
Root Causes
Our team examined the various drivers of VHA provider productivity,
and found there are several factors that limit the ability of providers
to optimize productivity. For example:
We found VHA providers have a lower room-to-patient ratio than the
private sector. Private sector room-to-provider ratios are typically 3-
to-1 and we found VHA providers typically only have a 1-to-1 ratio,
which does not allow them to see as many patients as their private
sector counterparts. Similarly, VHA providers have significantly fewer
nurses and administrative support staff, which means the providers
cannot be as efficient as they otherwise could be. Insufficient
clinical and administrative support staff results in providers and
clinical support staff not working to the top of their licensure.
Another challenge is VHA does not effectively manage nurse absences
(using nurse float pools), resulting in unplanned staff shortages and
fewer patients who can be treated.
While there has been widespread implementation of the Patient
Aligned Care Team (PACT) model in primary care clinics and the National
Nurse Staffing Methodology in many areas of inpatient care, there are
no current VHA standards for staffing levels and/or mix in specialty
clinics, with the exception of eye clinics.
Based upon our team's observations and the findings of Assessment F
(Clinical Workflow), we have concerns providers may not be properly
documenting all of their workload, which may explain some of the
difference in productivity across all facilities. During site visits
and interviews with VHA Central Office leaders, we consistently heard
concerns that providers do not fully document and accurately code all
of their clinical workload.
Grant Thornton's Recommendations
In formulating our recommendations in 2015, our team considered the
findings and recommendations of the other Veterans Choice Act
Assessments, prior reports by the VA Office of the Inspector General
(OIG), the Government Accountability Office (GAO) and other government
bodies available at the time.
In our report we offered five overarching recommendations to VHA
along with the supporting evidence for each recommendation, relevant
promising or best practices, and potential near-term actions or next
steps. We also provide a discussion of cross-cutting implementation
considerations that may be used to develop, enhance, or speed
implementation of the recommendations. By implementing these
recommendations, along with the recommendations of the other Veterans
Choice Act Assessments, VHA can - with the support of Congress - evolve
into a consistently high performing health system, enabling access to
high quality care in an efficient and cost effective manner.
Recommendation 1: VHA should improve staffing models and performance
measurement.
VA should evaluate the design and implementation of current VHA
staffing models to determine the extent to which they are sufficient to
meet the goals of VHA's population health focused model and ensure all
eligible Veterans have access to high quality, timely care. VHA should
conduct a program review of the implementation of the PACT staffing
model in primary care to identify the causes of the productivity
shortfalls and the impacts of these performance gaps on access to
quality care. VHA should develop and implement staffing models for
outpatient specialty care services and improve existing performance
measurement systems to realize the benefits of specialty care staffing
models. VHA should refine and implement the National Nurse Staffing
Methodology across inpatient services and improve the performance
measurement system to realize the benefits of the methodology.
To improve staffing and productivity measurement and better
determine the capacity of VHA specialty clinics, Grant Thornton's
assessment recommended the VHA gather data and assess the productivity
of fee-based providers, as well as conduct a work measurement study (or
verify existing workload data) to determine the volume and distribution
of workload each year to better match staffing requirements to demand.
Recommendation #2: VA Medical Centers should create the role of clinic
manager and drive more coordination and integration among providers
and support staff.
VA has an opportunity to increase the level of teamwork and
accountability among all outpatient clinic staff, especially in
specialty care services. This might be achieved by creating
multidisciplinary management teams for specialty clinics that include a
physician leader, nurse leader, and business administrator.
Alternatively, specialty clinics might establish a single or dual
reporting line and operating a model for providers and their clinical
and non-clinical support staff, so all of the members of the specialty
clinic team have more accountability to each other and the Service
Chief of the specialty.
Recommendation #3: VA Medical Centers should implement strategies for
improving management of daily staff variances, and include a
replacement factor for all specialties, including PACT.
With respect to managing staff absences, VA can improve the
management of daily staffing variances by implementing several
strategies that include intermittent float pools of support staff and
the inclusion of a replacement factor across all staffing
methodologies/models, to include PACT.
Recommendation #4: VA Medical Centers should implement local best
practices that mitigate space shortages within specialty clinics.
VA medical facilities should further study opportunities to
mitigate space shortages within specialty clinics. These include
strategies such as: standardized schedule templates, expanded clinic
hours, increased use of non-face-to-face encounters for follow-up
consults by specialty care, and system redesign initiatives to improve
patient flow within clinics.
Recommendation #5: VHA should improve the accuracy of workload capture.
VHA should conduct an audit of health record documentation and
current procedural terminology (CPTr) coding accuracy and reliability
to validate physician productivity measurement and that if the results
support it, evaluate the ability of commercially available computer
assisted coding (CAC) applications to assist providers with coding. The
creation of the role of clinic manager for Specialty Care clinics
should also be used to improve clinic management and coding practices.
Closing
In a health system comprised of more than 150 hospitals and nearly
1,400 community-based outpatient clinics - among other care settings -
determining the staffing levels, caseload, and productivity required of
VA providers to meet the needs of more than 9 million enrolled Veterans
is a complex task. Adequate provider staffing levels and a health care
system that enables its clinicians to be productive in delivering VHA's
population-health focused model of care are essential to meeting the
goals of timely, high quality care for our nation's Veterans. I applaud
this committee, the Department and the often overlooked dedication from
the VA health care providers and support staff who have chosen to serve
our nations' Veterans. Grant Thornton is grateful for the opportunity
to address this committee and to offer our analysis of the challenges
facing VA.
Prepared Statement of of Randall B. Williamson
VA HEALTH CARE
Improvements Needed in Data and Monitoring of Clinical Productivity and
Efficiency
Chairman Wenstrup, Ranking Member Brownley, and Members of the
Subcommittee:
I am pleased to be here today to discuss our report on clinical
productivity and efficiency at the Department of Veterans Affairs (VA).
\1\ As you know, VA's total budgetary resources for its Veterans Health
Administration (VHA) have increased substantially over the last decade,
rising from $37.8 billion in fiscal year 2006 to $91.2 billion in
fiscal year 2016. As VA's funding levels increase, it is increasingly
important that the department spend these funds wisely and ensure that
VA attains high levels of productivity among its clinical services and
operational efficiency to maximize veterans' access to care and
minimize costs.
---------------------------------------------------------------------------
\1\ GAO, VA Health Care: Improvements Needed in Data and Monitoring
of Clinical Productivity and Efficiency, GAO 17 480 (Washington, D.C.:
May 24, 2017).
---------------------------------------------------------------------------
Beginning in fiscal year 2013, VA began implementing clinical
productivity metrics to measure physician providers' time and effort to
deliver various procedures in 32 clinical specialties. \2\ In addition,
VA developed 12 statistical models to measure clinical efficiency at
VA's medical centers (VAMC). Under the models, VA calculates each
VAMC's utilization and expenditures for different high volume or high
expenditure components of health care delivery, such as emergency
department and urgent care, and determines the extent to which
utilization and expenditures differ from expected levels. The Office of
Productivity, Efficiency, and Staffing (OPES), within VA Central
Office, is responsible for calculating both the provider productivity
metrics and the VAMC efficiency models.
---------------------------------------------------------------------------
\2\ In 2012, VA's Office of Inspector General (OIG) recommended
that the department establish clinical productivity metrics for
providers at VA's medical centers. VA OIG, Veterans Health
Administration: Audit of Physician Staffing Levels for Specialty Care
Services. 11-01827-36. (Washington, D.C.: Dec. 27, 2012). Clinical
productivity refers to the workload performed by VA's clinical
providers over a given time period.
---------------------------------------------------------------------------
My testimony today summarizes the findings from our recent report
analyzing VA's clinical productivity metrics and efficiency models.
Accordingly, this testimony addresses (1) whether VA's clinical
productivity metrics and efficiency models provide complete and
accurate information on provider productivity and VAMC efficiency and
(2) VA's efforts to monitor and improve clinical productivity and
efficiency. In addition, I will highlight four key actions that we
recommended in our report that VA can take to improve the completeness
and accuracy of VA's productivity metrics and efficiency models and
strengthen the monitoring of clinical productivity and efficiency
across VA.
To conduct the work for our report, we examined the types of
providers and the clinical services captured in the underlying clinical
workload and staffing data that inform VA's metrics and models, as well
as the processes used to record these data. We reviewed VA
documentation and interviewed officials from VA Central Office and six
VAMCs, which we selected based on geographic diversity, differences in
facility complexity, and variation in their providers' performance on
VA's productivity metrics as well as variation in the VAMCs'
performance on VA's efficiency models for fiscal year 2015. \3\ We
examined the monitoring and any related improvement efforts of VA
Central Office, the six selected VAMCs, and the Veterans Integrated
Service Networks (VISN) that are responsible for overseeing the six
VAMCs. \4\ We reviewed VA documentation and interviewed VA Central
Office, VISN, and VAMC officials. As part of our review, we assessed
the completeness and accuracy of the information provided by VA's
clinical productivity metrics and efficiency models using federal
standards for internal control related to information, and we assessed
VA's monitoring efforts using federal standards for internal control
for information and monitoring. \5\ Further details on our scope and
methodology are included in our report. The work this statement is
based on was performed in accordance with generally accepted government
auditing standards.
---------------------------------------------------------------------------
\3\ The six VAMCs we selected are located in Atlanta, Georgia;
Baltimore, Maryland; Harlingen, Texas; Las Vegas, Nevada; Saginaw,
Michigan; and Salem, Virginia.
\4\ VA Central Office is responsible for managing and overseeing
the VA health care system and delegates certain responsibilities to its
VISNs.
\5\ GAO, Standards for Internal Control in the Federal Government,
GAO/AIMD 00 21.3.1 (Washington, D.C.: November 1999) and Standards for
Internal Control in the Federal Government, GAO 14 704G (Washington,
D.C.: September 2014). Internal control is a process effected by an
entity's oversight body, management, and other personnel that provides
reasonable assurance that the objectives of an entity will be achieved.
VA's Metrics and Models May Not Provide Complete and Accurate
---------------------------------------------------------------------------
Information on Clinical Productivity and VAMC Efficiency
We found that VA's productivity metrics and efficiency models may
not provide complete and accurate information on provider productivity
and VAMC efficiency. To the extent that VA's productivity metrics and
efficiency models do not provide complete and accurate information,
they may misrepresent the true level of productivity and efficiency
across VAMCs and limit VA's ability to determine the extent to which
its resources are being used effectively to provide health care
services to veterans.
Specifically, we identified the following limitations with VA's
metrics and models:
Productivity metrics are not complete because they do not
account for all providers or clinical services. Due to systems
limitations, the metrics do not capture all types of providers who
deliver care at VAMCs, including contract physicians and advanced
practice providers, such as nurse practitioners, serving as sole
providers. VA Central Office officials explained that VA data system
limitations and other factors have made it difficult for VA's
productivity metrics to capture the workload for all types of
providers. In addition, the metrics do not capture providers' workload
evaluating and managing hospitalized patients because VA's data systems
are not designed to fully capture providers' workload delivering
inpatient services that do not involve procedures-in particular,
evaluating and managing patients who are hospitalized.
Productivity metrics may not accurately reflect the
intensity of clinical workload. A 2016 VA audit shows that VA providers
do not always accurately code the intensity-that is, the amount of
effort needed to perform-of clinical procedures or services. As a
result, VA's productivity metrics may not accurately reflect provider
productivity, as differences between providers may represent coding
inaccuracies rather than true productivity differences.
Productivity metrics may not accurately reflect
providers' clinical staffing levels. Officials at five of the six
selected VAMCs we visited reported that providers do not always
accurately record the amount of time they spend performing clinical
duties, as distinct from other duties. VA's productivity metrics are
calculated for providers' clinical duties only.
Efficiency models may also be adversely affected by
inaccurate workload and staffing data. To the extent that the intensity
and amount of providers' clinical workload are inaccurately recorded,
some of VA's efficiency models examining VAMC utilization and
expenditures may also be inaccurate. For example, the model that
examines administrative efficiency requires accurate data on the amount
of time VA providers spend on administrative tasks; if the time
providers allocate to clinical, administrative, and other tasks is
incorrect, the model may overstate or understate administrative
efficiency.
To improve the completeness VA's productivity metrics, we
recommended that VA expand existing productivity metrics to track the
productivity of all providers of care to veterans by, for example,
including contract physicians who are not VA employees as well as
advance practice providers acting as sole providers. VA agreed in
principle with our recommendation and stated that it plans to establish
productivity performance standards for advanced practice providers,
using available productivity data, by October 2017. In its response,
however, VA did not provide information on whether it plans to expand
its productivity metrics to include providers who are not employed by
VA, such as contract physicians.
In addition, to improve the accuracy of VA's productivity metrics
and efficiency models, we recommended that VA help ensure the accuracy
of underlying workload and staffing data by, for example, developing
training for all providers on coding clinical procedures. VA agreed in
principle with our recommendation and reiterated its existing efforts
to improve clinical coding accuracy. It also said that the department
would reissue existing policy to VAMCs by June 2017 as well as continue
to provide need-based, focused coding training to providers, as
appropriate. However, VA did not provide information on how it plans to
improve the accuracy of provider staffing data, which inform VA's
productivity metrics and efficiency models.
VA Central Office Has Taken Steps to Help VAMCs Monitor and Improve
Clinical Productivity, but Does Not Systematically Oversee
Productivity and Efficiency across VA
We found that VA Central Office has taken steps to help VAMCs
monitor and improve provider clinical productivity but does not
systematically monitor VAMCs' clinical productivity remediation plans
and does not require and monitor remediation plans for addressing
clinical inefficiency. As a result, VA cannot ensure that low
productivity and inefficiencies are identified and addressed across VA.
Nor can VA systematically identify both the factors VAMCs commonly
identify as contributing to low productivity and inefficiencies as well
as best practices VAMCs have developed for addressing these issues. \6\
---------------------------------------------------------------------------
\6\ In its 2012 report, the VA OIG noted that information on
productivity can help VA identify best practices and those practices
that should be changed or eliminated. See VA OIG, Veterans Health
Administration: Audit of Physician Staffing Levels for Specialty Care
Services. 11-01827-36. (Washington, D.C.: Dec. 27, 2012).
---------------------------------------------------------------------------
In December 2016, VA Central Office began developing a
comprehensive analytical tool to help VAMCs identify the causes of low
productivity at their facilities, a process that would likely occur
after VA's productivity metrics have identified low productivity in one
or more clinical specialty at the facility. According to VA Central
Office officials, the comprehensive analytical tool VA is developing-in
the form of a data dashboard-is intended to centralize relevant data
sources, including data on clinic utilization, veterans' access to
care, and provider workload, and thereby allow VAMC officials to more
easily examine the factors contributing to low productivity. The
officials told us that they expect the data dashboard to be developed
in stages and rolled out to all VAMCs and VISNs over the course of
2017.
While VAMCs are required to monitor VA's productivity metrics and
may take steps to improve clinical productivity, VA Central office does
not have an ongoing process to systematically oversee these efforts. VA
policy requires VAMCs to develop remediation plans to address any low
productivity identified in their clinical specialties and submit these
plans to their VISN. Our review found that three of the six selected
VAMCs in our study were required to develop remediation plans, and
officials from these VAMCs stated that they submitted these plans to
their respective VISNs for review. However, we found that VA's policy
does not stipulate that VAMCs or VISNs are to submit approved
remediation plans to VA Central Office; nor does the policy stipulate
that VISNs or VA Central Office must monitor the implementation of
these remediation plans to ensure their success. As a result, for
example, officials at one of the VISNs we interviewed told us the VISN
does not monitor the implementation of VAMCs' remediation plans to
address low productivity.
Regarding VA's efforts to monitor efficiency, we found that while
VA Central Office officials encourage VAMCs to monitor and take steps
to improve clinical inefficiency at their facilities, VA policy does
not require VAMCs to use VA's efficiency models and address any
inefficiencies identified by them. In particular, VA has not
established performance standards based on these models and does not
require VAMCs to develop remediation plans to address inefficiencies.
\7\ According to VA Central Office officials, VA has not required VAMCs
to monitor these models and address any inefficiencies because VA
officials view the models solely as a tool to guide VAMCs in managing
their resources. In the absence of a monitoring requirement, we found
that two of the six VAMCs we visited had not taken steps to address
inefficiencies identified by VA's efficiency models.
---------------------------------------------------------------------------
\7\ VA's efficiency models are used to track VAMC utilization and
expenditures for various health care services and compare these
expenditures to expected levels.
---------------------------------------------------------------------------
Based on our findings, we recommended that VA develop a policy
requiring VAMCs to monitor and improve clinical inefficiency through a
standard process, such as establishing performance standards based on
VA's efficiency models, and develop remediation plans for addressing
clinical inefficiencies. VA concurred in principle with this
recommendation, stating that it would require VAMCs to develop
remediation plans. We also recommended that VA establish an ongoing
process to systematically review VAMCs' remediation plans and ensure
that VAMCs and VISNs are successfully implementing remediation plans
for addressing low clinical productivity and inefficiency. VA concurred
with our recommendation and told us it plans to review, twice a year,
the progress VAMCs are making in addressing low productivity and
inefficiency.
Chairman Wenstrup, Ranking Member Brownley, and Members of the
Subcommittee, this concludes my statement. I would be pleased to
respond to any questions that you may have at this time.
GAO Contacts & Staff Acknowledgments
If you or your staff members have any questions concerning this
testimony, please contact me at (202) 512-7114 ([email protected]).
Contact points for our Offices of Congressional Relations and Public
Affairs may be found on the last page of this statement. Other
individuals who made key contributions to this testimony include Rashmi
Agarwal, Assistant Director; Michael Zose, Analyst in Charge; Krister
Friday; Hannah Grow; and Jacquelyn Hamilton.
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Prepared Statement of Jonathan B. Perlin, MD, PhD
``Clinical Productivity and Efficiency in the Department of Veterans'
Affairs Healthcare System''
Good afternoon. I'm Dr. Jonathan Perlin, President of Clinical
Services and Chief Medical Officer for Nashville, Tennessee-based HCA
Healthcare. I would like to thank Committee Chairman Roe, Subcommittee
Chair Wenstrup, ranking member Brownley, and members of the
Subcommittee for this opportunity to comment on VHA Clinical
Productivity and Efficiency.
We are the nation's largest private healthcare provider, and have
the privilege of caring for patients through 28 million clinical
encounters annually. These include approximately 1.65 million
hospitalizations, 8.5 million emergency room visits, and more than
220,000 deliveries. We number about 241,000 employees, of whom
approximately 80,000 are nurses. These numbers are exclusive of nearly
37,000 voluntary physicians. We see patients at 168 hospitals and more
than 1,200 other sites of care, including surgical centers, free-
standing emergency rooms, urgent care, and physician offices across 42
markets in 21 states. In other words, we are similarly-sized to the
Veterans Health Administration.
We are proud to acknowledge that included in our dedicated
healthcare workforce are many Veterans and military spouses. We invest
in employing service members, and in 2016 alone, we hired more than
5,400 military Veterans and 1,100 military spouses. In 2015, the U.S.
Chamber of Commerce Foundation awarded HCA the ``Hiring Our Heroes Lee
Anderson Veteran and Military Spouse Employment Award.''
I believe that I have a unique perspective to offer the Committee,
having served as Chief Quality Officer, Deputy Under Secretary and
Under Secretary for Health, as well as - like the Secretary, Dr.
Shulkin - as a VA physician during my tenure in these roles.
I appreciate the opportunity to support the work of the Committee
and the Department in providing the most effective and efficient care
for America's Veterans. In his 100-day briefing at the White House,
Secretary Shulkin offered 13 observations on areas he considered risks
for VA. He and his team came to these conclusions from both a business
and clinical perspective. While there is no need for me to recount them
here, a few are worth noting, as they are directly responsive to some
of the concerns that the GAO report identifies. I will augment his
observations with mine, bringing current private-sector perspective on
how we manage productivity within our organization.
Dr. Shulkin's first diagnosis of risk concerned access. I will not
recount all of the statistics, but would note that his comments
identify substantial progress overall, increased same-day access for
primary and certain specialty services and some remaining opportunities
for improvement. Obviously, increases in provider efficiency are an
important means for creating additional capacity and access.
The second area of concern involves prompt payment of external
providers. This is an area in which legislative relief would be
helpful. Consolidation of disparate models for obtaining services
outside of VA and, frankly, comportment with Medicare or private
insurer reimbursement models would facilitate provider participation
and Veteran access to services. The complexity of the different models
imposes statutory inefficiencies in VA's overall management of care
within and outside of VA.
The third area noted by Dr. Shulkin was quality. VA is to be
commended for making their star ratings public. VA is increasingly
benchmarking against private sector, and in many instances, VA
performance is as good, if not better. I note these areas because they
are salient to GAO's central observations on VA provider productivity.
-GAO first notes that ``Productivity metrics are not complete
because they do not account for all providers or clinical services.''
Secretary Shulkin's recent expansion of scope-of-practice for advanced
practitioners will both increase productivity and present an increasing
challenge in recording and benchmarking productivity. Indeed, VA is apt
to become the reference point for advanced practitioner productivity,
to the extent that data systems can attribute the work performed to
advanced practitioners individually or in the aggregate.
-GAO further notes that ``metrics do not capture providers'
workload evaluating and managing hospitalized patients.'' This is a
challenge for all entities that provide team-based care. The
attribution of workload to certain members of the team, beyond the
attending physician, is notoriously complex, as has been demonstrated
in long-standing debate regarding attribution of quality and safety
metrics. This is demonstrated by, for example, contention over who
receives credit for a positive quality outcome (for example, a care
episode without a vascular catheter infection) or blame for a safety
breach (for example, a hospital-acquired infection). This is
problematic because many hands touch the patient, and data systems
don't capture every touch. While data systems could be designed for
attribution of effort, workload needs to be captured as a by-product of
work, otherwise it would be inefficient, requiring providers to spend
as much time designating their work, as doing their work.
-GAO's next observation that ``Productivity metrics may not
accurately reflect the intensity of clinical workload'' has roots to
some degree in the same phenomenon - does extra effort required for
coding workload compete with actual work and productivity? On the other
hand, as VA has announced the decision to re-platform its electronic
record, this would be an ideal time to consider how to embed tracers of
workflow that can transparently capture productivity. I would note that
in our organization, when we think about the care of hospitalized
patients, rather trying to capture every individual's action, we
summarize by looking at ``employee equivalents per occupied bed.''
- The GAO Report further notes that ``A 2016 VA audit shows that VA
providers do not always accurately code the intensity of . . . clinical
procedures or services. As a result, VA's productivity metrics may not
accurately reflect provider productivity, as differences between
providers may represent coding inaccuracies rather than true
productivity differences.'' Again, documentation improvement to capture
the patient's service intensity requirement is something that private
sector has become highly proficient in doing, as it is simultaneously
the basis for clinical risk adjustment, as well as the basis for
graduated payment levels. Similarly, this - and ``recording (clinician)
time performing clinical duties'' - are area that VA's new electronic
health record should assist with improving.
-I would agree prima facie with the statement that ``efficiency
models may also be adversely affected by inaccurate workload and
staffing data'' and that the impact may lead to either understating or
overstating efficiency.
-On the basis of my experience with VA management systems of more
than a decade ago, as well as my research in preparing for this
hearing, I would also agree with GAO's finding ``that VA Central Office
has taken steps to help VAMCs monitor provider productivity by
developing a comprehensive analytical tool VAMCs can use to identify
the drivers of low productivity.''
-GAO's exhortation to ``systematically oversee VAMCs' efforts to
monitor clinical productivity and efficiency . . . and systematically
identify best practices to address low productivity and inefficiency''
is a central challenge for management of multi-facility health systems
across the United States. Certainly, it is a central focus for our
organization and, in this regard, VA and HCA share an operating
advantage: Both systems are large enough to look for positive
variation. If the underpinnings of better performance can be
understood, replicated and scaled, it becomes the means to elevate the
performance of the entire system.
-Understanding variation within the system and comparison with
external performance standards is why both internal and external
benchmarking are necessary: Internal benchmarking allows systems to tap
into the data that they have to identify both positive and negative
variation. Internal benchmarking is a tool for learning and management.
It can function as one part of a control system for facility, VISN and
VACO leadership to manage performance. External benchmarking is
necessary to understand whether internal performance is superior,
consistent with or inferior to external organizations. External
benchmarking is limited by differences in data availability and data
definitions among organizations.
-VA's ``SAIL'' system provides elements for both internal and
external benchmarking, and I would again agree with GAO's assessment
that this is a useful management tool for all of the reasons I've
noted.
I would note that the biggest challenges to external benchmarking
are not related to data, but rather certain inherent features of VA and
the patients it serves:
First, Veterans using VA are systematically more complex patients
than commercially-insured or even mixed commercial/government-covered
(i.e., general Medicare or Medicaid) populations. So, some of the
external references, such as the MGMA (Medical Group Management
Association) benchmarks may need to be tempered. Better reference
environments may be safety net providers, in terms of patient
complexity, as well as academic health systems that - like VA - have a
simultaneous teaching responsibility.
Second, the VA benefits package is systematically different that
either commercial insurance or other government programs, like Medicare
or Medicaid. VA's breadth of services means that there are more things
that a provider can, should and must do during a clinical encounter. In
a capitated system, it is rational to take all necessary actions for
preventive services or other interventions that reduce the need for
future services or subsequent interventions. Again, the tension between
work and recording work arises.
Third, RVU's were developed for fee-for-service environments and,
as such, are intended to make provider compensation proportional to
recorded effort. This obviously incentivizes both work and the
recording of work. Private sector enjoys different flexibility in
provider compensation models, so when clinicians are employed by a
provider organization, provider compensation can be calibrated to
productivity. In our organization, we always look at productivity,
compensation and quality together. While provider performance on
quality is a non-negotiable expectation, we can calibrate compensation
appropriately.
Fourth, in our organization, our physical plants and adjunctive
staffing models are oriented to enhancing productivity. It is
systematically inefficient for a clinical provider to operate from only
one or two exam rooms and with one or fewer support staff. My
understanding is that despite some spectacular new facilities, VA still
has opportunity to improve its aged plants and associated staffing
models.
Fifth, there may be times when it is inefficient or inappropriate
for VA to internally produce all of the care Veterans need. I agree
with the Secretary's perspective to use private sector services when
geographic access, wait times, capacity, demonstrated clinical
performance excellence or technology are not available in VA. On the
other hand, VA has demonstrated excellence in serving as a medical and
health home for the most complex of patients. Indeed, many Veterans
using VA are patients with multiple medical and social challenges -
such as serious mental illness, advanced physical illness, poverty and
other vulnerabilities directly related to their statutory eligibility
for VA care - that challenge private-sector performance and distinguish
VA. That continuity-of-care and coordination of services (including
medical and social) that VA provides is not only special, but not
directly replicable in private sector.
Finally, and in closing, it is obligatory to look at productivity
and quality simultaneously. Quality and safety are always most
efficient: rework for breaches in either is neither efficient, nor
consistent with the performance excellence that taxpayers deserve and
that Veterans should expect and have earned through their service and
sacrifice. Again, my thanks to the Subcommittee for this opportunity,
and we look forward to working with you and Secretary Shulkin to
accomplish these objectives.
Prepared Statement of Carolyn Clancy, M.D.
Good afternoon, Chairman Wenstrup, Ranking Member Brownley, and
Members of the Subcommittee. Thank you for the opportunity to discuss
the clinical efficiency and productivity of providers in VA. I am
accompanied today by Dr. Murray Altose, Chief of Staff for the Louis
Stokes VA Medical Center (VAMC) in Cleveland, Ohio.
VA's mission is to provide Veterans with the best healthcare they
have earned and deserve. However, we also must be good stewards of
taxpayer dollars, which fund this care. This means making sure that our
facilities and systems are organized to facilitate optimal productivity
and efficiency, particularly on the front lines of care. Clinical
productivity is the sum of both clinical activity and the effectiveness
of the team supporting that clinician. This means that a productive and
efficient facility has both high-performing clinicians and support
staff.
In 2013, we implemented clinical productivity metrics to measure
physician providers' time and effort to deliver procedures. VA also
developed statistical models to track clinical efficiency at VAMCs.
Data collected under the metrics and models are used to identify
clinical productivity and efficiency levels. Reports are designed to
provide leaders in our facilities and networks with essential tools to
understand which clinics are working under, at, or over capacity.
Physician Staffing and Productivity Standards
VA has adopted an activity-based productivity and staffing model
for specialty physicians. Utilizing an industry accepted Relative Value
Unit (RVU)-based model, specialty physician productivity standards have
been developed and implemented. In fiscal year (FY) 2013, productivity
standards for six specialties (dermatology, neurology,
gastroenterology, orthopedics, urology, and ophthalmology) were
developed, piloted in four Veteran Integrated Service Networks (VISN)
and then implemented nationwide.
A critical component of the productivity and staffing standard
implementation is the Specialty Productivity-Access Report and Quadrant
(SPARQ) tool that provides an algorithm for the effective management of
VHA's specialty physician practices. This tool is designed to assess
specialty physician practice business strategies and drive performance
improvement in Veterans' access to specialty care. This tool was
recognized as one of the most important managerial tools developed in
support of physician productivity and staffing standards and its
ability to go beyond standard implementation to ultimately drive system
performance.
The SPARQ tool includes important measures, such as support staff
ratios for specialty physicians so as to maximize physician efficiency.
The SPARQ tool measures the care team, including advanced practice
providers such as Nurse Practitioners, Physician Assistants, and
Clinical Nurse Specialists, and their RVU contribution. The SPARQ tool
also measures specialty physician value in the form of ``compensation
per RVU'' so as to demonstrate our ability to be good stewards of
public healthcare resources.
We are pleased to report measurable progress as demonstrated by
increased RVUs. VHA's system-wide focus on improving access to care,
prioritizing urgent clinical needs and achieving same-day access for
Veterans with urgent primary care or mental health needs, has resulted
in increased clinical output (clinical workload up 13 percent) with a
concurrent increase in RVUs per clinical employee of 9 percent.
Government Accountability Office (GAO) Report
On June 23, 2017, the GAO released a report (GAO-17-480) titled
``Improvements Needed in Data and Monitoring of Clinical Productivity
and Efficiency.'' GAO identified limitations with VA's metrics and
models that limit VA's ability to assess whether resources are being
used effectively.
GAO found that productivity metrics are not complete because they
do not account for all providers or clinical services due to data
systems limitations. The metrics also do not capture providers'
workload evaluating and managing hospitalized patients. Also,
productivity metrics may not accurately reflect the intensity (the
amount of effort needed to perform) of clinical workload. As a result,
VA's productivity metrics may not accurately reflect provider
productivity, as differences between providers may represent coding
inaccuracies rather than true productivity differences. Furthermore,
productivity metrics may not accurately reflect providers' clinical
staffing levels. GAO found that providers do not always accurately
record the amount of time they spend performing clinical duties. In
turn, efficiency models may also be adversely affected by this
inaccurate workload and staffing data. GAO made four recommendations
and VA concurred with each:
1.Expand existing productivity metrics to track the productivity of
all providers of care to Veterans by, for example, including contract
physicians who are not employees as well as advance practice providers
acting as sole providers;
2.Help ensure the accuracy of underlying staffing and workload data
by, for example, developing training to all providers on coding
clinical procedures;
3.Develop a policy requiring VAMCs to monitor and improve clinical
efficiency through a standard process, such as establishing performance
standards based on VA's efficiency models and developing a remediation
plan for addressing clinical inefficiency; and
4.Establish an ongoing process to systematically review VAMCs'
remediation plans and ensure that VAMCs and VISNs are successfully
implementing remediation plans for addressing low clinical productivity
and inefficiency.
VA Response to Recommendations
VA concurred with GAO's recommendations and is already working to
complete them. We have already expanded productivity measurement to
include Advanced Practice Providers (APP) and will establish
productivity performance targets for them. Since 2014, the Office of
Productivity, Efficiency and Staffing (OPES) has maintained a
comprehensive database of the APP workforce and workload. This
database, the APP Cube, provides detailed information by discipline
about the APP staffing levels, clinical workload, and productivity for
each VAMC. We collect this data and post it on the VHA Support Service
Center (VSSC) website. We are currently in the process of establishing
standards for these advanced practice providers, for whom we recently
expanded practice authority across the system.
We recognize that our current productivity and efficiency
monitoring does not represent a 100-percent solution, but it does move
VHA toward our goal of ready access to high-quality, efficient
healthcare for our Veterans. Significant work has been undertaken to
improve productivity and efficiency. For example, data tools to assist
local VAMCs are readily available and are used with increasing
frequency. As one indicator, the number of web hits on these
productivity and efficiency tools within the system - which shows local
managers are working on initiatives to improve productivity and
efficiency - has increased by 37 percent (up from 462,742 to 631,912)
from the second quarter of FY 2016 to the same time in FY 2017.
VA concurred in principle with the second recommendation, to
develop coding training for all providers. VA utilizes appropriate
needs-based, focused training to minimize the impact on access to care.
In May 2016, VHA's Health Information Management (HIM) program office,
in conjunction with the Office of Compliance and Business Integrity,
developed and implemented a process to improve coding accuracy and
report monitoring of clinical coders and providers and monitoring
productivity of coders. The process includes the appropriate sample
size of billable and non-billable events per facility along with a
standardized data collection tool. The facility chief of HIM collects
appropriate data, reports results to the facility Compliance Committee
and, as appropriate, develops a causation and corrective action plan
for facility implementation to include focused provider training as
deemed necessary. Regular presentations by the Compliance Committee
assure leadership visibility of progress in improving productivity and
efficiency. The HIM program office examines data to identify patterns
across VHA sites and develops education remediation efforts. This is
then reissued to the field.
We have also undertaken a comprehensive education and communication
plan about the specialty physician productivity and staffing standards.
We have held national calls to actively engage our specialty physician
workforce. Our specialty physicians are committed to demonstrating and
improving specialty productivity and access. We have also held national
calls with medical center leadership in an effort to communicate
clearly the expectations of full implementation of specialty physician
productivity and staffing standards. All medical centers have been
provided with access to a variety of tools that permit productivity and
staffing measurement at the individual physician and specialty practice
level. Our national and local specialty leaders have been trained on
the business strategies and tools available to assist them in managing
their specialty practices with the goal of ready access to quality
specialty care for our Veterans.
VA also concurred in principle with the third recommendation, to
monitor and improve efficiency through a standard process. The Deputy
Under Secretary for Health for Operations and Management (DUSHOM) will
develop a more comprehensive strategy regarding VAMC clinical
efficiency by leveraging current clinical efficiency models. The
DUSHOM's preferred approach is to continue our present course of
enhancing and updating tools that highlight potential opportunities to
improve clinical efficiency, and to strengthen the organization's
capacity to disseminate proven, strong practices from high performers
and, for struggling sites, to provide personalized, on-site assistance.
Currently, staff from the DUSHOM's office sits down weekly with field
colleagues to identify outlier facilities for follow-up who may have
reported unusual increases or decreases in productivity. Plans for
improving clinical efficiency must be developed at the VAMC.
Remediation plans should be tracked at both the facility and VISN. The
DUSHOM will review the progress VAMCs are making on the remediation
plans for addressing low clinical productivity twice a year with the
VISN. The target completion date for this is March 2018.
Finally, VA concurred with GAO's recommendation to establish an
ongoing process to review and ensure success of these remediation
plans. OPES already provides ongoing reporting of productivity
performance to the VAMC leadership. In addition, the DUSHOM will review
the progress VAMCs are making on the remediation plans for addressing
low clinical productivity and efficiency twice a year with the VISN.
The target completion date for this is October 2017.
We are currently exploring a productivity measurement system and
performance targets for Physician Assistants and Nurse Practitioners.
This is a complicated matter and involves deliberation with multiple
stakeholders who are less accustomed to workload documentation than our
physicians. Our current Veterans Information Systems and Technology
Architecture (VistA) data architecture was never designed to capture
data related to billing type, so a variety of complex workarounds are
needed to assemble an approximation of RVUs. These workarounds
introduce a risk of reporting inaccurate numbers; and we magnify that
risk by expanding the scope of measurement. We are encouraged by the
fact that the anticipated Cerner system is better configured for
workload capture and billing using private-sector standards, and could
help embed workflow indicators that transparently capture data
regarding productivity and minimize inaccuracies due to our current
workarounds. Many private hospitals now rely on integrated applications
to reduce coding errors and inefficiency. Capturing the productivity of
contract physicians is currently not possible because, while we can
track workload, we do not have any centralized data for total effort or
time.
The 2015 Independent Assessment
In 2015, the Independent Assessment required by Section 201 of the
Veterans Access, Choice, and Accountability Act of 2014 made five
similar recommendations regarding productivity and efficiency: (1) VHA
should improve staffing models and performance measurement; (2) VAMCs
should create the role of clinic manager and drive more coordination
and integration among providers and support staff; (3) VAMCs should
implement strategies for improving management of daily staff variances,
and include a replacement factor for all specialties, including Patient
Aligned Care Teams; (4) VAMCs should implement local best practices
that mitigate space shortages within specialty clinics; and (5) VHA
should improve the accuracy of workload capture.
In response to the Independent Assessment, VA has taken several
steps described below to ensure increased efficiency and productivity
and therefore improve access to care and better use of taxpayer
dollars. As a result, VA has made great improvements since the
publication of the Independent Assessment to improve overall
productivity and efficiency.
As previously mentioned, the SPARQ tool provides data to assist
leadership with local resource decisions. This includes data on the
practice infrastructure and projected clinical workload from the
Enrollee Healthcare Projection Model. VHA reports provider productivity
by specialty and medical center complexity group. Specialty practices
not meeting productivity targets are required to identify a remediation
plan, with VA Central Office and VISN leadership actively involved in
this review. Similarly, Specialty Practice Triggers are in place to
identify significant changes in clinical workload volume and
productivity.
As a result of the Veterans Access, Choice, and Accountability Act
of 2014, we have Group Practice Managers (GPM) at all of our facilities
who oversee staffing and clinic flow. They represent one of the most
exciting initiatives that VHA has implemented recently. The GPMs are
charged with specialty practice management and have quickly and adeptly
begun addressing the myriad issues in optimizing our clinic practice in
real time.
Conclusion
VA appreciates our colleagues at GAO's efforts and the efforts of
others to improve clinical efficiency and productivity. VHA's top
priority is improving access to care for our Veterans; improving
productivity and efficiency is a means to that end.
Mr. Chairman, I am proud of the healthcare our employees provide to
our Nation's Veterans. Together with Congress, I look forward to making
sure that VA will be a good steward of taxpayer dollars, while
providing this care in a productive and efficient manner. Our Veterans
deserve this care and our taxpayers deserve to know we are providing it
in the most efficient and productive manner. Thank you for the
opportunity to testify before this Subcommittee. I look forward to your
questions.
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