[House Hearing, 118 Congress]
[From the U.S. Government Publishing Office]


                   VA'S FEDERAL SUPREMACY INITIATIVE:
                        PUTTING VETERANS FIRST?

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

                                HEARING

                               BEFORE THE

                         SUBCOMMITTEE ON HEALTH

                                 OF THE

                     COMMITTEE ON VETERANS' AFFAIRS

                     U.S. HOUSE OF REPRESENTATIVES

                    ONE HUNDRED EIGHTEENTH CONGRESS

                             FIRST SESSION

                               __________

                      TUESDAY, SEPTEMBER 19, 2023

                               __________

                           Serial No. 118-30

                               __________

       Printed for the use of the Committee on Veterans' Affairs
       
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]       


                    Available via http://govinfo.gov
                              __________

                   U.S. GOVERNMENT PUBLISHING OFFICE                    
53-767                     WASHINGTON : 2024                    
          
-----------------------------------------------------------------------------------                    
                   
                     COMMITTEE ON VETERANS' AFFAIRS

                     MIKE BOST, Illinois, Chairman

AUMUA AMATA COLEMAN RADEWAGEN,       MARK TAKANO, California, Ranking 
    American Samoa, Vice-Chairwoman      Member
JACK BERGMAN, Michigan               JULIA BROWNLEY, California
NANCY MACE, South Carolina           MIKE LEVIN, California
MATTHEW M. ROSENDALE, SR., Montana   CHRIS PAPPAS, New Hampshire
MARIANNETTE MILLER-MEEKS, Iowa       FRANK J. MRVAN, Indiana
GREGORY F. MURPHY, North Carolina    SHEILA CHERFILUS-MCCORMICK, 
C. SCOTT FRANKLIN, Florida               Florida
DERRICK VAN ORDEN, Wisconsin         CHRISTOPHER R. DELUZIO, 
MORGAN LUTTRELL, Texas                   Pennsylvania
JUAN CISCOMANI, Arizona              MORGAN MCGARVEY, Kentucky
ELIJAH CRANE, Arizona                DELIA C. RAMIREZ, Illinois
KEITH SELF, Texas                    GREG LANDSMAN, Ohio
JENNIFER A. KIGGANS, Virginia        NIKKI BUDZINSKI, Illinois

                       Jon Clark, Staff Director
                  Matt Reel, Democratic Staff Director

                         SUBCOMMITTEE ON HEALTH

               MARIANNETTE MILLER-MEEKS, Iowa, Chairwoman

AUMUA AMATA COLEMAN RADEWAGEN,       JULIA BROWNLEY, California, 
    American Samoa                       Ranking Member
JACK BERGMAN, Michigan               MIKE LEVIN, California
GREGORY F. MURPHY, North Carolina    CHRISTOPHER R. DELUZIO, 
DERRICK VAN ORDEN, Wisconsin             Pennsylvania
MORGAN LUTTRELL, Texas               GREG LANDSMAN, Ohio
JENNIFER A. KIGGANS, Virginia        NIKKI BUDZINSKI, Illinois

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public 
hearing records of the Committee on Veterans' Affairs are also 
published in electronic form. The printed hearing record remains the 
official version. Because electronic submissions are used to prepare 
both printed and electronic versions of the hearing record, the process 
of converting between various electronic formats may introduce 
unintentional errors or omissions. Such occurrences are inherent in the 
current publication process and should diminish as the process is 
further refined.
                         
                         
                         C  O  N  T  E  N  T  S

                              ----------                              

                      TUESDAY, SEPTEMBER 19, 2023

                                                                   Page

                           OPENING STATEMENTS

The Honorable Mariannette Miller-Meeks, Chairwoman...............     1
The Honorable Julia Brownley, Ranking Member.....................     2

                               WITNESSES
                                Panel 1

Dr. Jesse Ehrenfeld, MD, President, American Medical Association.     3

Dr. Paul Barney, OD, American Optometric Association.............     5

Ms. Janet Setnor, MSN, CRNA, Col (Ret) USAFR, NC, President 
  Elect, American Association of Nurse Anesthesiology............     7

Dr. Stephen D. McLeod, MD, Chief Executive Officer, American 
  Academy of Ophthalmology.......................................     8

Dr. Ron Harter, MD, FASA, President-Elect, American Society of 
  Anesthesiologists..............................................    10

                                Panel 2

Dr. Erica Scavella, MD, FACP, FACHE, Assistant Under Secretary 
  for Health for Clinical Services, Chief Medical Officer, 
  Veterans Health Administration, Department of Veterans Affairs.    23

        Accompanied by:

    Dr. M. Christopher Saslo, DNS, ARNP-BC, FAANP, Assistant 
        Under Secretary for Health for Patient Care Services, 
        Chief Nursing Officer, Veterans Health Administration, 
        Department of Veterans Affairs

    Mr. Ethan Kalett, Executive Director Office of Regulations 
        Appeals in Policy, Veterans Health Administration, 
        Department of Veterans Affairs

                                APPENDIX
                    Prepared Statements Of Witnesses

Dr. Jesse Ehrenfeld, MD Prepared Statement.......................    43
Dr. Paul Barney, OD Prepared Statement...........................    51
Ms. Janet Setnor, MSN, CRNA, Col (Ret) USAFR, NC Prepared 
  Statement......................................................    59
Dr. Stephen D. McLeod, MD Prepared Statement.....................    72
Dr. Ron Harter, MD, FASA Prepared Statement......................    86
Dr. Erica Scavella, MD, FACP, FACHE Prepared Statement...........    94

                       Statements For The Record

The American Legion..............................................    97
National Conference of State Legislatures........................   117
American Nurses Association......................................   132

                          APPENDIX--continued

Nursing Community Coalition......................................   133
American Academy of Family Physicians............................   136
Jewish War Veterans of the USA...................................   141
American Society of Retina Specialists...........................   144
American Association of Nurse Practitioners......................   145
Blinded Veterans Associations....................................   149
Fleet Reserve Association........................................   151
American Pharmacists Association.................................   152
VA Document For the Record, Briefings and Engagements............   157

 
       VA'S FEDERAL SUPREMACY INITIATIVE: PUTTING VETERANS FIRST?

                              ----------                              


                      TUESDAY, SEPTEMBER 19, 2023

             U.S. House of Representatives,
                    Committee on Veterans' Affairs,
                                    Subcommittee on Health,
                                                   Washington, D.C.
    The subcommittee met, pursuant to notice, at 10:16 a.m., in 
room 360, Cannon House Office Building, Hon. Mariannette 
Miller-Meeks [chairwoman of the subcommittee] presiding.
    Present: Representatives Miller-Meeks, Radewagen, Bergman, 
Murphy, Van Orden, Luttrell, Kiggans, Brownley, Levin, Deluzio, 
Budzinski, and Landsman.
    Also present: Representative Davis.

   OPENING STATEMENT OF MARIANNETTE MILLER-MEEKS, CHAIRWOMAN

    Ms. Miller-Meeks. Good morning. I now call the hearing of 
the Subcommittee on Health Oversight to order.
    I would like to start out by asking that Representative 
Scott be allowed to join our Subcommittee and be allowed to sit 
at the dais in order to participate in today's hearing 
proceedings.
    Hearing no objection, so ordered.
    You may sit.
    I never had an opportunity to do that, so.
    As a 24-year Army veteran physician and a former nurse, I 
strongly believe that veterans deserve the utmost quality in 
care. I actually met my husband Kurt, who was an Licensed 
Practical Nurse (LPN) at the time, while we were both serving 
at Walter Reed.
    Having served in these positions both as a student nurse 
married to an LPN who became a Bachelor of Science Nursing 
(BSN) nurse and a nurse and a doctor, and then the former 
director of the Iowa Department of Public Health which had a 
lot to do with licensure and scope of practice, I believe I 
have a deep understanding of providing safe and effective care 
and it remains one of my top priorities in Congress and to 
ensure that veterans receive the same quality of care as those 
seeking care in private hospitals.
    The VA issued an interim final rule known as the Federal 
Supremacy initiative in 2020. Through this initiative, VA is 
working on establishing national standards for over 50 
healthcare occupations regardless of state scope of practice 
laws. VA has stated standardizing a set of practices that 
healthcare providers can perform within the Federal VA system 
would help when needing to transfer care workers between 
different VA medical centers depending on where care is needed 
most.
    Well, I do not argue that this might provide some greater 
uniformity within the VA, VA clinicians of all types were able 
to move quickly throughout the VA system during the pandemic 
when critical needs arose in certain localities.
    Although this interim rule was published approximately 2 
years ago, VA has not yet considered or opened up a comment 
period for majority of healthcare occupations. It remains a 
concern to me and many other members on this Committee that the 
VA has not been clear and as engaged about some clinical 
specialties, specifically specialties that require a 
significant investment in training and practice to ensure 
patient safety and board certification.
    It is imperative that the VA is transparent about this 
process and standards to avoid confusion among providers and 
patients, especially when there are wide variations in state 
licensure laws.
    During today's hearing, I look forward to examining the 
process and development of these standards. Additionally, I am 
eager to better understand how these standards will affect 
patient care in the future.
    I want to be clear. I am not here to play one profession 
against the other. I have the utmost respect for every 
clinician who devotes their life to the care of patients and 
especially of veterans.
    With that I yield to the Ranking Member Brownley for her 
opening statement.

      OPENING STATEMENT OF JULIA BROWNLEY, RANKING MEMBER

    Ms. Brownley. Thank you, Chairwoman Miller-Meeks. Thank you 
for holding today's hearing to examine VA's ongoing National 
Standards of Practice (NSP) initiative.
    As the chairwoman just said, let me also say, because I 
want to be clear as well at the outset of this hearing, that I 
hold the utmost respect for all of the dedicated healthcare 
professionals who work at VA medical facilities nationwide 
including all the physicians, nurse practitioners, physician 
assistants (PA), Certified Registered Nurse Anesthetists 
(CRNAs), optometrists, and other healthcare providers. They 
show unwavering commitment day in and day out to caring for 
veterans, and their contributions to VA healthcare systems are 
invaluable.
    However, as we embark on this examination of VA's National 
Standards of Practice initiative, it is imperative that we 
consider the unique needs of veterans, many of whom have 
extreme and complex needs and unique medical conditions 
resulting from their service. Ensuring that veterans receive 
the highest level of care demands a thorough evaluation of the 
roles, responsibilities, and training of all healthcare 
providers within the VA system.
    I firmly believe that physicians with their extensive 
medical training and clinical experience play a pivotal role in 
providing comprehensive care for veterans, particularly when it 
comes to complex medical conditions, surgical procedures, and 
advanced treatments.
    My own son is a physician, so I have observed firsthand the 
tens of thousands of hours of intense study and training it 
takes to become a physician. Veterans like all Americans 
deserve access to the full spectrum of medical expertise 
available to address their healthcare needs.
    Throughout this hearing I look forward to engaging in a 
constructive and fact-based dialog to better understand the 
implications of VA's National Standards of Practice initiative 
on the quality of care provided to veterans. Together we must 
ensure that veterans receive the highest standard of care and 
that their healthcare needs are met by providers with the 
appropriate qualifications and expertise. I look forward to 
continuing the discussion we began at a closed-door roundtable 
this past April where we heard from each of the organizations 
represented on our first panel of witnesses today. At that 
time, stakeholders representing physician groups expressed 
frustration about what they viewed as a lack of transparency 
and engagement by VA. They said they had sent letters that had 
gone unanswered and that they had not had meaningful 
opportunities to engage with Veterans Health Administration 
(VHA) officials involved in the National Standards of Practice 
initiative. I have heard that the VA has made a greater effort 
to engage these groups in the ensuing months and that is 
something I hope to hear more about today.
    One thing I brought up at the roundtable which I still do 
not feel has been thoroughly addressed by VA is why, given all 
of the other priorities competing for the attention of senior 
leadership, the department has chosen to undertake this 
initiative. We are already approaching 3 years since the start 
of the National Standards of Practice initiative without VA 
having finalized standards for any of the 51 occupations yet. 
If there was truly an urgent need to undertake this process one 
would think more progress would have been made by now. I hope 
today's hearing will shed more light on VA's justification for 
undertaking this long, drawn out process to develop a National 
Standards of Practice.
    I thank all of our witnesses and colleagues for their 
participation and candor in this crucial discussion.
    With that, Madam Chair, I yield back.
    Ms. Miller-Meeks. Thank you, Ranking Member Brownley.
    I would now like to introduce the witnesses.
    On our first panel we have Dr. Jesse Ehrenfeld, president 
of the American Medical Association (AMA); Dr. Paul Barney with 
the American Optometric Association; Ms. Janet Setnor, 
president elect of the American Association of Nurse 
Anesthesiology (AANA); Dr. Stephen McLeod, chief executive 
officer of the American Academy of Ophthalmology; and Dr. Ron 
Harter, president elect of the American Society of 
Anesthesiologists (ASA).
    Dr. Ehrenfeld, you are now recognized for 5 minutes to 
deliver your opening statement.

                  STATEMENT OF JESSE EHRENFELD

    Dr. Ehrenfeld. Good morning, Chairwoman Meeks, Ranking 
Member Brownley, members of the Subcommittee. Thank you for 
having me here today.
    My name is Dr. Jesse Ehrenfeld. I am a practicing physician 
and president of the American Medical Association. I am a 
former Navy commander. I have a background in military 
medicine. I am on the faculty of the Uniformed Services 
University deployed to Kandahar, Afghanistan during OBF.
    I can choose to get my own healthcare pretty much anywhere. 
For the past 7 years I have chosen to get all of my medical 
care at the VA because I believe in the VA, its people, and 
what it can offer.
    The implementation of these National Standards of Practice 
is a very personal issue. This project concerns me because I 
believe that our Nation's veterans, my shipmates, will receive 
lower quality of care of this project is implemented. In 
medicine, our goal is to match the expertise of the person 
delivering the care to the needs of the patient receiving the 
care. It is why their busiest down reach facilities which 
handle the most complex injuries in battle the Department of 
Defense (DOD) sends physicians to lead care teams. It is why 
today when a patient having cardiothoracic surgery at the VA, 
they receive their care from physicians who lead the care team.
    However, the Supremacy Project will make it next to 
impossible for the VA to match the most qualified clinician 
with the needs of the veterans, potentially allowing 
nonphysicians to perform procedures that are beyond their scope 
of knowledge and state licensure.
    This is concerning because expanding the scope of practice 
for nonphysician practitioners increases costs and jeopardizes 
patient safety.
    The VA Evidence Based Synthesis Program found that there 
was no evidence to support the safe implementation of nurse-
only models of anesthesia care. A study in the National Bureau 
of Economic Research compared the productivity of independently 
practicing nurse practitioners and physicians in a VA emergency 
department. The study found that nurse practitioners use more 
resources and result in worse health outcomes than physicians.
    For this reason, physician-led teams are the gold standard 
in medicine, which is further illustrated by the fact that 45 
states do not allow nurse anesthetists to practice independent, 
and 42 states do not allow optometrists to perform eye laser 
surgery.
    If this project moves forward, models of care that are 
rarely used in the private sector will be formalized across the 
VA. This will make the VA an outlier in the medical community, 
erode public trust in the system, and lead to worse health 
outcomes for our veterans. The nonphysicians, such as nurse 
anesthetists, pharmacists, optometrists, physician assistants 
are integral members of the care team. The skills acumen 
obtained by physicians throughout their extensive education and 
training makes them uniquely qualified to oversee and supervise 
veterans care.
    To ensure our veterans receive the care that they have 
earned, physicians need to remain as leaders of the care team. 
If there are universal standards for each profession then the 
most vigorous state scope requirements should be implemented.
    In closing, I want to recognize and thank all those who 
have served, especially practitioners who brought their skills 
and their training to the battlefield. As the administration 
and Congress consider the implementation of this project, it is 
imperative to remember four points. There are important 
distinctions between care provided in battle and that of 
routine planned care provided to veterans that typically have 
comorbidities due to age and service-connected disabilities. 
Though I choose to get my care at the VA, there are many 
veterans that must receive their care at the VA because they 
have no other option. We must ensure that they receive the best 
care possible, that of physician-led team-based care. As 
leaders of a care team, physician representation on all the VA 
workers, not just the physician workers, should be mandatory.
    Finally, it is unclear why this project is needed. The VA 
originally rationalized that they needed this project because 
of privileging issues with the new EHR. In follow-up meetings 
the VA then stated the project was needed to move personnel 
around the system. These shifting rationales do not make sense 
and do not align with how good medicine is practiced.
    As we all work together to ensure that the VA is the best 
healthcare system it can be, let us truly consider the 
implications of the Federal Supremacy Project and the negative 
impact it will have on our veterans.
    Thank you so much for having me here and I look forward to 
your questions.

    [The Prepared Statement Of Jesse Ehrenfeld Appears In The 
Appendix]

    Ms. Miller-Meeks. Thank you, Dr. Ehrenfeld.
    Dr. Barney, you are now recognized for 5 minutes to deliver 
your opening statement.

                    STATEMENT OF PAUL BARNEY

    Dr. Barney. Thank you and good morning.
    My name is Dr. Paul Barney, and I am here today 
representing the American Optometric Association.
    I live and practice in Anchorage, Alaska, where I have 
served as a center director for the Pacific Cataract and Laser 
Institute for nearly 25 years. I believe that I bring a 
valuable perspective to today's discussions as I am a 
practicing Doctor of Optometry who routinely provides laser and 
other surgical care to my patients.
    I did part of my training at an Army hospital and at a VA 
outpatient clinic. As an adjunct professor at two U.S. 
optometry schools, I am involved in training the next 
generation of frontline eye doctors. As a lecturer, I help keep 
my colleagues on the cutting edge of patient care.
    I also understand what it is like to live in a community 
faced with a shortage of medical doctors and other providers. 
Roughly 40 percent of counties or county equivalents in the 
U.S. have access to a Doctor of Optometry but not an 
ophthalmologist. That number is expected to grow.
    America's Doctor of Optometry are stepping up to fill that 
gap. Optometry's training and abilities have continued to 
advance alongside the evolution of technology. Today's rigorous 
4-year optometry school curricula focuses exclusively on the 
study of ocular health and vision care. Laser and surgical 
education, both didactic and hands on is embedded and is a key 
part of optometric education at both the optometry school level 
and the post-doctoral level. In fact, contrary to what 
detractors say, laser and surgical care has been and continues 
to be taught at each and every school and college of optometry 
in the country.
    Doctors of Optometry are licensed to practice by their 
state and their scope of practice is set by the state's laws 
and regulations. The trend for the past 50 years has been for 
states to increase optometric scope of practice. In no case has 
their scope of practice been reduced.
    In 10 states, doctors of optometry are authorized to use 
lasers to treat ocular conditions. In one state, Oklahoma, 
optometrists have been providing laser eye care for nearly 30 
years. State regulators cite that this authority has led to an 
increase in access to care particularly in the states 
underserved in rural areas. Those state officials also report 
little or no patient complaints have resulted from this 
increase in scope of care.
    Further, malpractice rates for doctors of optometry in 
states with the authority to provide laser eye care and other 
contemporary procedures are roughly identical to rates in 
states without that authority which highlights the safety and 
efficacy of this care provided by optometrists.
    Aside from in-house care at VA, all Federal health programs 
recognize, cover, and pay for doctors of optometry to provide 
laser and other surgical procedures covered under the state's 
scope of practice. Medicare, Medicaid, and the Indian Health 
Service all cover and pay for the full range of services 
authorized under an optometrist's state scope of practice.
    Similarly, all major private payers cover and pay for laser 
eye care and other surgical procedures included in an 
optometrist's state's scope of practice. The VA's own Community 
Care program recognizes that injections, lasers, and eye 
surgery can be provided by an optometrist based on the 
licensure of the provider.
    Eye and vision care ranks as the third most requested 
service by veterans. Doctors of optometry provide roughly 
three-quarters of all eye and vision care in the VA. With 
optometrists often being the only eye care provider at many VA 
facilities what the department decides to include or exclude 
from the Optometry National Standards of Practice will have an 
outsized impact on access and timeliness of care, which will 
affect patient outcomes and veteran quality of life for years 
to come.
    The veteran service organization, American Veterans 
(AMVETS) has repeatedly urged the VA to ensure that any VA 
policy ensure veteran access to the full range of care that 
both ophthalmologists and optometrists are authorized to 
perform, including lasers and other surgical procedures. AMVETS 
has shared concerns that if the VA does not get it right, its 
members may not have the same access or choices that other 
citizens in their states enjoy.
    At a time when the VA is struggling to meet veteran demand 
for eye care, it is important that the VA cut through the noise 
and do what is right for veterans by advancing an optometry NSP 
that recognizes and ensures veteran access to the full range of 
care including laser eye care and other surgical procedures 
that doctors of optometry are trained, licensed, and fully 
capable of providing. Thank you.

    [The Prepared Statement Of Paul Barney Appears In The 
Appendix]

    Ms. Miller-Meeks. Thank you, Dr. Barney.
    Ms. Setnor, you are now recognized for 5 minutes to deliver 
your opening statement.

                   STATEMENT OF JANET SETNOR

    Ms. Setnor. Good morning, Chairwoman Miller-Meeks, Ranking 
Member Brownley, and members of the Subcommittee. Thank you for 
the invitation today to speak on veterans' care.
    I am Jan Setnor. I am a colonel retired from the United 
States Air Force Reserves with 26 years of service as a CRNA, a 
flight nurse, and a senior staff member for the Air Force 
Surgeon General.
    As a CRNA who has served as both the anesthesia element 
team lead over both physician anesthesiologists and CRNAs in 
the largest in-country medical facility in Afghanistan and a 
sole anesthesia provider for the Special Forces Operating Base, 
I know firsthand that unrivaled anesthesia care is provided by 
CRNAs without duplicative or unnecessary supervision. I have 
practiced independently in the most difficult circumstances 
while serving in the military.
    CRNAs work without supervision in the Army, the Navy, the 
Air Force, and in countless facilities across the country. If 
CRNAs are called upon to competently and safely deliver 
anesthesia in the battlefield without supervision, it is 
reprehensible to restrict that care to our veterans here at 
home.
    As a practicing CRNA, I am frustrated that my profession is 
constantly having to defend its value purely for political and 
self-serving financial reasons when many peer reviewed studies 
have proven CRNA care is safe, effective, and par with other 
providers. In fact, the VA in its 2016 final rules stated that 
CRNAs provide high quality care. Additionally, 90 percent of 
veteran households in a survey stated that they support 
allowing access to CRNAs within the VA.
    CRNAs also grow weary of hearing the physician 
anesthesiologists' false narrative that the VA is planning to 
replace all anesthesiologists with CRNAs or that CRNA education 
is inadequate. These are outright falsehoods. The AANA 
maintains that both anesthesiologists and CRNAs should be 
available to provide direct patient services and that VA 
facilities should be allowed to choose their most suitable 
anesthesia delivery model.
    There has been too much political influence on nonphysician 
scope of practice decisions. The AMA and physician groups have 
a vested financial interest in limiting the scope of practice 
for other providers. According to their own website, the AMA 
has spent over $3.5 million to impede Advanced Practice 
Registered Nurses (APRNs) from practicing to the top of their 
education and training.
    I would be remiss if I did not address the Hattiesburg 
article currently being shared with Congress by our medical 
colleagues.
    This study (1) Reviews only nurse practitioners and 
physician assistants in emergency room settings; (2) Does not 
include or even apply to CRNAs; (3) Does not look at CRNA or 
optometrist practice and has no relevance to the national 
standards for our profession.
    Yet, our medical colleagues dishonestly tried to 
extrapolate from this deeply flawed study and draw fallacious 
conclusions regarding supervision.
    However, the VA's strategic plan released last year 
highlighted in a study showing full practice authority for 
other APRNs has had a very positive effect on wait times for 
the veterans.
    Removing barriers to care, including removal of wasteful 
and financially motivated supervision requirements is not 
controversial and is supported by many organizations that do 
not have a vested or self-serving financial interest in 
maintaining this antiquated status quo. These include two past 
administrations, the Bipartisan Policy Center, the AARP, the 
National Rural Association, the Brookings Institute, and the 
Americans for Prosperity among others.
    The men and women who have selflessly served our Nation 
deserve timely and quality care. All scientific evidence and 
multiple independent groups have concluded that that is CRNA 
care.
    In conclusion, I would like to commend Chairwoman Miller-
Meeks' Iowa VA facilities for setting the standard of what a 
great collaborative, full practice CRNA physician 
anesthesiologist practice looks like. It is noteworthy that 
Iowa was the first state in the Nation to opt out of physician 
supervision for anesthesia care. In both Iowa City and Des 
Moines facilities, all CRNAs practice independently to the full 
extent of their education and training; thus, enabling the 
physician anesthesiologist to do their own cases. This 
decreases wait times, increases access to quality care, and 
improves patient safety and satisfaction. All providers do high 
acuity, complex cases and all take call independent of each 
other. Both facilities consistently rank amongst the most 
highly rated of VA facilities and they invite you to come and 
shadow them at any time you wish to see this in progress.
    Thank you very much for your time. I appreciate it.

    [The Prepared Statement Of Janet Setnor Appears In The 
Appendix]

    Ms. Miller-Meeks. Thank you, Ms. Setnor.
    Dr. McLeod, you are now recognized for 5 minutes to deliver 
your opening statement.

                  STATEMENT OF STEPHEN MCLEOD

    Dr. McLeod. Good morning, Chairwoman Miller-Meeks, Ranking 
Member Brownley, and members of the Subcommittee.
    My name is Dr. Stephen McLeod. I am the chief executive 
officer of the American Academy of Ophthalmology. I have served 
in this role since 2022. Prior to that I was chair of the 
Department of Ophthalmology at the University of California San 
Francisco, 17 years, and served as a staff ophthalmologist at 
the San Francisco VA Medical Center.
    I am here today on behalf of the American Academy of 
Ophthalmology to voice our deep concern that veterans will be 
put at risk if the VA adopts national standards that allow 
optometrists to perform surgery.
    First let me say that we strongly believe that optometrists 
are vital members of the eye care team. During my tenure at 
University of California San Francisco (UCSF) I actively 
developed these collaborative team-based models and continue to 
support them as a national model of care. However, our efforts 
recognize the different training, skill, and expertise of each 
team member. I must emphasize that as medical doctors with 
extensive surgical training, indeed many thousands of hours 
devoted specifically to eye surgery, only ophthalmologists 
possess the expertise and the experience required to perform 
eye surgery and to address the potential complications that 
might arise.
    The VA must exercise extraordinary caution when it comes to 
setting standards for allowing eye surgery. Eye tissue is 
extremely delicate and unforgiving. The surgery is considered 
amongst the most technically challenging and damage is simply 
impossible in cases to repair.
    Currently, the vast majority of states, 41, do not allow 
optometrists to perform laser surgery. There are a handful of 
states representing a small fraction of the U.S. population 
that allow other surgical procedures but even within these 
states, optometrists scopes of practice vary considerably.
    Optometrists are restricted from performing surgery in most 
states in the VA system for a reason. Optometrists are not 
trained to safely perform surgical procedures. Optometry 
training primarily focuses on the correction of refractive 
error, glasses and contact lenses, and on primary eye care. 
While the curriculum includes some didactic education on 
surgical topics, meaningful hands-on surgical training is not 
included.
    In states where optometrists have been granted limited 
surgical privileges, training often consists of a condensed 32-
hour certification course conducted at a hotel venue, not a 
clinical facility. There is no hands-on patient surgical 
experience which is obviously a crucial component for 
competent, safe, and successful eye surgery. An optometrist 
trained under these circumstances may, in fact, attempt their 
first, unsupervised laser cases having never used the equipment 
on a human eye.
    There is also evidence that suggests that patients who 
receive surgical procedures from optometrists experience poor 
outcomes. A 2016 study published in the Journal of the American 
Medical Association of Ophthalmology, found that there was 
nearly triple the likelihood of repeat laser treatment in the 
same eye when the surgery was performed by optometrists 
compared to same surgery done by ophthalmologists.
    Now, the stated goal of the VA Supremacy initiative is to 
develop national standards that ensure that our veterans 
receive the same high quality care regardless of where they 
enter the system. Extending surgical privileges to a subset of 
providers with vastly inferior training based only on location 
violates both fundamental principles--quality and consistency 
regardless of entry point.
    To compound this further, it is possible that the VA would 
grant optometrists licensed in one state the privilege to 
perform surgery nationwide, potentially overriding state 
specific laws and expanding risks to patients across the VA. 
For example, an optometrist licensed in Oklahoma could be 
allowed to perform laser surgery in Iowa even though Iowa, like 
40 other states, for safety reasons prohibits optometrists from 
performing laser surgery.
    As I conclude, I will share my own state's experience. 
Nearly a year ago, California Governor Newsom vetoed Assembly 
Bill 2236 which would have allowed optometrists to perform 
surgical procedures. In his message the Governor stated, and I 
quote, ``I am not convinced that the education and training 
required is sufficient to prepare optometrists to perform the 
surgical procedures identified. This bill would allow 
optometrists to perform advanced surgical procedures with less 
than 1 year of training.''
    We cannot allow our Nation's veterans to receive complex 
surgical procedures from those who simply do not have the 
training and expertise to perform them. All of our Nation's 
veterans need and deserve the highest level of care, and that 
means regardless of site, only surgeons should perform 
surgeries.''
    Thank you again for the invitation today. I look forward to 
your questions.

    [The Prepared Statement Of Stephen McLeod Appears In The 
Appendix]

    Ms. Miller-Meeks. Thank you, Dr. McLeod.
    Dr. Harter, you are now recognized for 5 minutes to deliver 
your opening statement.

                    STATEMENT OF RON HARTER

    Dr. Harter. Good morning. Thank you, Chairwoman Miller-
Meeks and Ranking Member Brownley. I am here on behalf of the 
56,000 members of the American Society of Anesthesiologists.
    We strongly believe that VA's proposed move to a nurse-only 
model of anesthesia care is a solution in search of a problem. 
A solution that could risk veterans lives, especially toxic 
exposed veterans.
    There is no shortage of anesthesiologists in VA. As of 
yesterday there were only 22 position vacancies for 
anesthesiologists in VA out of 1,000 total positions. The 
average vacancy rate for anesthesiologists this year is just 2 
percent, well below the national average.
    VA has the right anesthesia policy in place right now. It 
is consistent with what every top-rated civilian hospital 
provides, what 45 states requires, and what VA reaffirmed in 
2016 after years of thorough review.
    VA is going to tell you that there is no evidence from 
impartial, independent studies to indicate the full practice 
authority for CRNAs leads to either improved or adverse 
outcomes.
    A lack of evidence is not the same as a demonstration of 
safety. VA has not met the burden of proof to show evidence 
that CRNA-only care is safe. Congressional action is required. 
VA addressed this burden of proof question in 2014 when VA's 
own researchers conducted the Quality Enhancement Research 
Initiative (QUERI) study that specifically questioned whether 
more complex surgeries can be safely managed by CRNAs providing 
anesthesia alone.
    Without meeting this burden of proof, VA is risking the 
health and lives of veterans with its proposed policy. VA has 
an ethical obligation to meet its burden of proof that it will 
not harm veterans before putting in place a new policy that not 
one top-rated civilian hospital allows.
    This issue cannot be fully addressed without consideration 
of The Sergeant First Class Heath Robinson Honoring our Promise 
to Address Comprehensive Toxics (PACT) Act Veterans. It makes 
no sense for VA to spend billions of dollars to treat PACT Act 
veterans with respiratory disease and then fail to provide them 
with the same level of anesthesia care delivered at all leading 
civilian hospitals.
    This Committee and its members were instrumental in the 
passage of the PACT Act. Toxic-exposed PACT Act veterans have 
acquired lung disease that typically increases the risk of 
anesthesia.
    These veterans have the right to ask this question. Since 
the passage of the PACT Act, has VA conducted an independent 
study of the increased risks of anesthesia on toxic-exposed 
veterans.
    Anesthesiologists and CRNAs are not interchangeable. Using 
basic common sense, there are 100 anesthesiologist members of 
ASA who were CRNAs before they made the decision to go to 
medical school for 4 years, and then 4 years of residency. Why 
would they spend years of their life doing that if there was 
nothing more for them to learn. They decided to pursue those 
additional years of rigorous medical education and training to 
prepare them to make the split second decisions that can mean 
the difference between life and death.
    I have spent most of my career teaching and training 
medical students and residents in the medical specialty of 
anesthesiology. Although nurse anesthetists are truly 
outstanding advanced practice nurses, they are not 
anesthesiologists. CRNAs are educated and trained to work with 
anesthesiologists as a member of a team, not to practice 
medicine.
    In fact, with one exception, every CRNA training program is 
located in a state that requires a CRNA to work with a 
physician in the delivery of anesthesia care. Any claim that 
CRNAs are trained to practice without physician supervision is 
not accurate.
    Despite various nursing organizations suggesting the CRNA-
only model is commonplace. The CRNA-only model is rare. Only 5 
states permit the CRNA-only model of care, and even in those 
states it is used infrequently. All other states require 
physician involvement with CRNAs, whether it be supervision, 
direction, collaboration, or other state-specific terms. 
Whatever the terminology, CRNAs in 45 states must work with a 
physician.
    Finally, I was pleased to read the American Legion's 
statement and respect them for seeking veterans' thoughts about 
this important issue. They found that 91 percent of respondents 
support the physician-delivered and physician-led anesthesia 
care team model. Nearly three-quarters believe that dismantling 
or altering this model will subject veterans to a lower 
standard of care than civilians receive.
    Chairwoman Miller-Meeks, Ranking Member Brownley, and 
members of the Subcommittee, thank you for your time and 
attention to this issue which is critical to our veterans.
    I welcome your questions.

    [The Prepared Statement Of Ron Harter In The Appendix]

    Ms. Miller-Meeks. Thank you, Mr. Harter. We will now 
proceed to questioning.
    As has been my custom, I will delay my question to the end.
    Before I go to the first questioner, the first member, I 
just want to say to all of our witnesses, for those who have 
served, thank you for your service. To those who serve our 
veterans at a VA facility, thank you for serving our veterans.
    With that, the chair now recognizes Representative Bergman.
    Mr. Bergman. I am recognized?
    Ms. Miller-Meeks. Yes, sir.
    Mr. Bergman. Okay. Thank you, Madam Chairwoman.
    Members of the military do not get to excited about a lot 
of things, but what we do get excited about negatively is we 
use the term in the Pentagon, ``protecting rice bowls.'' You 
all know what that means. You have got your little rice bowl of 
appropriations and all those things that you do. That is human 
nature. You all are not alone in that.
    When I started as a Marine, I started in rice paddies. If 
you get the drift in the late `60's, early `70's. I really was 
not concerned about rice bowls, and I would suggest there are 
veterans of today who served in places like Iraq and 
Afghanistan, they are not interested in rice bowls. They are 
interested in what they observed in the desert and experienced 
in the mountains and all of that in different ways.
    One of the challenges we have as a Committee is to separate 
what is a rice bowl that is being protected for the right 
reasons or not. I thank both sides of the aisle on this 
Subcommittee especially to make sure that we are doing the 
right thing for the right reason, for the veterans in all cases 
regardless of which rice bowl it may fall in.
    Having said that, Dr. Barney, am I correct to understand 
that under Medicare, Medicaid, and Indian Health Service, all 
cover and pay for the full range of services authorized under 
an optometrist state scope of practice, and in addition, all 
major private payers cover and pay for those services including 
laser eye care and other contemporary procedures included in an 
optometrist's state scope of practice?
    Dr. Barney. Yes. That is correct.
    Mr. Bergman. Okay. With all of that being true, would it be 
correct to say that VA is currently an outlier among all 
private payers and other Federal programs? Could you speak to 
the impact that this could have on our veterans' access to, in 
this particular case, eye care?
    Dr. Barney. Yes. I think that would be a correct statement, 
especially if you consider VA's Community Care Program. The 
Community Care Program does pay for laser procedures provided 
by an optometrist outside the VA facility itself. If there is a 
restrictive optometry NSP, I would foresee a scenario where a 
veteran would not be able to get access to laser eye care by an 
optometrist within the facility but it could go outside the 
facility and receive that care. To me that seems like not a 
very wise use of VA funds and resources.
    Mr. Bergman. Thank you.
    Ms. Setnor, can you discuss the role that nurse 
anesthetists play in rural and remote areas, in this case like 
Michigan's 1st District, which is not only rural, it is really, 
really remote?
    Ms. Setnor. CRNA's cover almost 100 percent of the rural 
health medicine in most of the states. Several facilities are 
now closing down because of an inability for access to have 
these care models delivered. I could say that with certainty 
that CRNAs practice independently in these settings.
    Mr. Bergman. Okay. Thank you.
    Finally, Dr. Harter, can you point to any evidence that 
shows VA is trying to replace anesthesiologists as you say the 
ASA has claimed?
    Dr. Harter. The move to remove physician supervision simply 
would have that opportunity arise. That there could be VA 
facilities that might for various reasons opt to not have 
physician anesthesiologists if they are no longer required to 
be present.
    Mr. Bergman. Okay. We think that might be an outcome at 
this point but nothing has occurred to this point to point to 
the fact of a lower standard of care?
    Dr. Harter. Well, we would be, I think, speculating as to 
what might happen one way or another.
    Mr. Bergman. Well, that is okay, because we have to, in all 
cases now--I see I have got about 20 seconds left--we need to 
make sure as best we can as Members of Congress that what is 
being done at all bureaucratic levels within the Federal 
Government, in this case especially Veterans Administration, 
that it is being done for the right reasons with outcomes for 
veterans in mind, not outcomes for the bureaucracy.
    With that I yield back.
    Ms. Miller-Meeks. Thank you, Representative.
    The chair wants to issue a sincere apology to Ranking 
Member Brownley for going out of order.
    I now recognize Ranking Member Brownley for any questions 
she may have.
    Ms. Brownley. No worries, Madam Chair. Not at all.
    My first question really is to the physician groups that 
are here testifying because I just want to get some clarity. At 
our roundtable meeting that Dr. Miller-Meeks and I had back in 
April, there was testimony there that said that the VA was not 
really being transparent and/or responsive. I just want to get 
some clarification. The VA says that they are reaching out so I 
want to get some clarification from you, where you stand on 
that issue.
    Dr. Ehrenfeld.
    Dr. Ehrenfeld. Thank you for the question. I really 
appreciate it.
    The VA has not involved the AMA in the development, 
implementation, or decision-making around the Supremacy 
Project. Since we became aware of this in 2021, we have made it 
clear to the VA that we would love to be involved. We would 
love transparency. I think that is how we separate out whether 
this is a rice bowl or a rice paddy.
    Ms. Brownley. Dr. McLeod.
    Dr. McLeod. We have been somewhat frustrated by a 
difficulty in really being able to get clarity. We do think 
that it is moving in the right direction. You know, from our 
perspective, an entire process that is looking at delivering 
eye care within the VA where the eye care is going to be 
delivered by optometrists and by ophthalmologists, that does 
not bring both groups into the room at the same time to come up 
with the most rational way of dealing with the patients' needs 
is not in the best interest of the patients and that has not 
happened.
    Ms. Brownley. Thank you.
    Dr. Harter.
    Dr. Harter. Much the same. We have requested to have 
opportunity to have discussions about this specific to nurse 
anesthesia practice under the proposed National Standards of 
Practice and to this point have not had the opportunity to 
provide that.
    Ms. Brownley. Right. Dr. Barney, do you have anything to 
say with respect to my question?
    Dr. Barney. They have been communicative with us. We have 
not been involved with all the details but they have been 
communicative with us, so.
    Ms. Brownley. Thank you.
    Ms. Setnor.
    Ms. Setnor. Yes, ma'am. All your physicians have been 
involved--had an opportunity to participate at various levels.
    Ms. Brownley. I apologize on your name.
    Ms. Setnor. No worries.
    Ms. Brownley. I will get it right the next time. I promise.
    You know, I have been on this Committee for 10 years. I am 
not a doctor, so let me be clear about that. I will say it has 
been the VA who convinced me early on that a team-based model 
is the best model and the gold standard. I think someone 
mentioned the gold standard in terms of healthcare. You know, 
the VA has also asserted in its testimony and during recent 
staff briefings that its National Standards of Practice 
initiative will not eliminate nor change the department's 
current team-based model of care. I do not know if everyone is 
confused. I am a little confused because I hear testimony that 
this is not the direction the VA is going in. The VA is saying 
they are going to hold on to the model of care. I guess I want 
to ask you what is your definition or what does a team-based 
model of care mean? If we can be brief in the answers because I 
think most will say it is physician-led. Some may not.
    I will start again with Dr. Ehrenfeld.
    Dr. Ehrenfeld. Thank you for the question. It is really 
important. The AMA strongly supports physician-led team-based 
care. Nobody should be practicing in a silo and that means 
nobody should be practicing by themselves.
    Ms. Brownley. Dr. Barney.
    Dr. Barney. Yes. We support physician-led care. Keep in 
mind that optometrists are physicians.
    Ms. Brownley. Thank you.
    Ms. Setnor.
    Ms. Setnor. Team-based care, in the Air Force if you look 
at our statutes, it actually says that the team-based model is 
actually the best but it also states that the team lead can 
also be a CRNA as well as an anesthesiologist. It is the 
experience and level that you are looking at.
    As explained when I was deployed, we worked as a team. 
Anesthesia is not a one-man sport. It takes a whole team to 
conduct anesthesia in a facility. You need the surgeon. You 
need our whole team to make it happen. In essence, it is a team 
sport and either person can be team lead.
    Ms. Brownley. Dr. McLeod.
    Dr. McLeod. In our space some ambiguity has been lent to 
the term ``physician,'' and so we will be specific. In our 
space we believe that it should be an ophthalmologist-led team.
    Ms. Brownley. Dr. Harter.
    Dr. Harter. Not surprisingly, we also feel that it should 
be physician-led care.
    I do want to say, to make a distinction, we are not 
advocating that it must be anesthesiologist-led care. There are 
certainly settings, both in the private sector as well as 
within the VA where currently the physician providing that 
supervision is the operating surgeon. Any thoughts that this 
will somehow create better access, reduce costs, et cetera, 
they are able to do that model currently without removing any 
need for physician oversight of the nurse anesthetist.
    Ms. Brownley. Thank you. My time is up but I do have more 
questions. I am hoping that we may have another opportunity, 
Madam Chair.
    Ms. Miller-Meeks. Thank you, Ranking Member Brownley.
    The chair now recognizes Dr. Murphy for his questions.
    Mr. Murphy. Thank you, Madam Chair. Thank you to the 
members. I want to thank you all of you guys for coming out and 
dedicating your lives to the practice of taking care of people. 
I do not see any greater cause personally and professionally. I 
have done one for 35 years and I much prefer the title of 
doctor rather than Congressman.
    Do not take that the wrong way. Sorry, folks.
    That said, being a doctor is in my DNA and these scope of 
practice issues are always coming up. It is like playing whack-
a-mole sometimes. I call it scope creep. The term is I want to 
practice to the highest level of my license. I absolutely 
understand. I think it is imperative that folks understand 
where that phrase comes from and what it means. Who gets to 
determine what your license is, your peers? It is not someone 
who does a procedure by training and has done it 10,000 times. 
It is something that your peers say, hey, I think you should be 
able to do this. When you say I want to practice to the level 
of my license, it is really a misnomer as to what you are 
saying. It is really saying I want to practice to the level of 
what my friends and my colleagues say I can practice. It is not 
practicing to the level of what people who have actually done 
specific training in that field say you can do.
    That said, there is overlap. There is obviously overlap. I 
am a urologist and gynecologist. There is plenty of overlap. 
There is plenty of overlap between differing fields. When it 
comes to surgery, and it comes to keeping somebody alive under 
anesthesia, the overlap really hits a wall. I worked with nurse 
anesthetists. Have for 35 years. Have wonderful relationships 
with them. Absolutely. When the proverbial hits the fan, I want 
an anesthesiologist in the room. I have had many, many, many 
circumstances because I am a cancer surgeon. I have done a lot 
of cancer surgeries. When someone's like is at stake, I want 
the person with the highest level of training to be there.
    I wear glasses. Thank God for my optometrist or I would be 
fumbling more than I actually fumble around anyway. That said, 
I personally do not believe a weekend course, a couple week 
course, it is fine when you know a narrow band of knowledge and 
that is fantastic. You may know that. As we all know there are 
complications that step outside here. There are complications 
that step out here. Unless you know the depth and the breadth 
of what is in that field of pathology, I do not fully feel you 
know the disease process that you are working with.
    The VA, talking with anesthesia, is not having a problem 
getting anesthesiologists right now. Optometrists and 
ophthalmologists may be a little bit different things. I 
understand. I absolutely understand that you are all passionate 
for wanting to take care of our veterans. Absolutely. There is 
nobody in this room that is not passionate for wanting to take 
care of our veterans. In my opinion, in my medical opinion, 
there is a team concept and there has to be one quarterback. 
One quarterback for a team. If not it is absolute anarchy. Yes, 
there are some gray areas and there are some definite 
partnerships between CRNAs and anesthesiologists without a 
doubt. There are excellent partnerships between optometrists 
and ophthalmologists. Absolutely. Some see post-op patients and 
everything. When we use the scope creep and the term of 
practicing to the highest ability of my license, it is a little 
bit, and this may across the wrong way, it is a little bit 
disingenuous because where you got that license from is really 
not where the expertise lies.
    I do not have any specific questions because I think you 
guys know where I stand. I want everybody under the same tent 
because the same tent is that which cares for our veterans. 
Lessening in my opinion the quality of care because of a 
perceived access issue really is not what our veterans deserve. 
They are not what our veterans deserve. I do believe there can 
be some common ground to help our VA achieve care for all of 
our veterans but I do not believe in decreasing the quality of 
care and the expertise of care.
    With that, Ms. Chairman, I will yield back.
    Ms. Miller-Meeks. Thank you, Dr. Murphy.
    The chair now recognizes Mr. Van Orden for 5 minutes.
    Mr. Van Orden. Thank you, Madam Chair.
    Dr. Setnor, I understand that you served in Afghanistan. 
What years was that or were those?
    Ms. Setnor. 2008.
    Mr. Van Orden. Okay.
    Ms. Setnor. I am not a doctor.
    Mr. Van Orden. Okay, sorry, ma'am.
    Ms. Setnor. You can call me colonel if you want.
    Mr. Van Orden. I think that is what this is all about?
    I will, Colonel. I will tell you what. I am going to praise 
you publicly for the work that you did in secret because if you 
were in Afghanistan in 2008, there is a 100 percent chance that 
you are responsible for saving the lives of some of my Navy 
Seal brothers. I want to thank you for that.
    Ms. Setnor. Thank you.
    Mr. Van Orden. Actions speak louder than words. I am from 
the State of Wisconsin. Behind that door my staff has brought 
you some cheddar cheese from the State of Wisconsin.
    Ms. Setnor. Yay.
    Mr. Van Orden. To quote the president, ``That is not a 
joke.''
    Doctor Ehrenfeld, do you consider yourself a subject matter 
expert in the medical field?
    Dr. Ehrenfeld. Yes, sir.
    Mr. Van Orden. Good. Do you consider the American Medical 
Association the gold standard for medical expertise and advice?
    Dr. Ehrenfeld. I am very proud of what the AMA is able to 
represent in serving the needs of our patients and physicians.
    Mr. Van Orden. That is not the question I asked you.
    Do you consider the AMA the gold standard for medical 
expertise and advice?
    Dr. Ehrenfeld. I am not sure I can answer that, sir.
    Mr. Van Orden. Okay. Is smoking bad for you?
    Dr. Ehrenfeld. Yes, sir.
    Mr. Van Orden. Is using class 1 narcotics for recreational 
use bad for you?
    Dr. Ehrenfeld. Yes, sir.
    Mr. Van Orden. If you put an unprotected hand in fire will 
it be burned?
    Dr. Ehrenfeld. Yes, sir.
    Mr. Van Orden. Can a biological male become a biological 
female?
    Dr. Ehrenfeld. I am not sure I understand the question.
    Mr. Van Orden. That is the problem, Doctor?
    Can a biological male become a biological female?
    Dr. Ehrenfeld. I am not sure where you are going with that, 
sir.
    Mr. Van Orden. That is even more troubling.
    The issue is this. You know the answer to that question. 
You are just not going to say it because you are playing 
politics with medicine. So is your organization. That is not 
just dangerous; it is terrifying. So for my opinion, you are 
not a subject matter expert in the medical field or you are 
exercising administrative cowardice because you know the answer 
to that question, Commander.
    Doctor Hartner----
    Dr. Harter. Harter.
    Mr. Van Orden. What is it again?
    Dr. Harter. Harter.
    Mr. Van Orden. Oh, sorry about that.
    You submitted a 17-page biography and CV. You submitted 
less than a single page of written testimony and yet you spoke 
for 5 minutes. That is correct. That is all I got, man.
    Dr. Harter. Our written testimony was several pages. I 
cannot speak to the disconnect.
    Mr. Van Orden. Oh, when did you give us the updated one?
    Dr. Harter. I believe it was at the end of last week. I do 
not know exactly. The 15th.
    Mr. Van Orden. Okay.
    My concern is this, sir. Can you positively demonstrate a 
dearth of care for veterans due to a lack of anesthesiologists 
in the VA?
    Dr. Harter. With respect to wait times, et cetera?
    Mr. Van Orden. Yes.
    Dr. Harter. No. We are not aware of that being certainly 
global. I cannot speak to every VA facility in the country 
but----
    Mr. Van Orden. Okay.
    Dr. Harter. Again, our knowledge is that there are very few 
vacancies for anesthesiologists within the VA system which 
would suggest that staffing is appropriate throughout the 
system.
    Mr. Van Orden. Okay. When my colleague General Bergman was 
asking you about these things you said you were not going to 
speculate on this and that; correct?
    Dr. Harter. Correct.
    Mr. Van Orden. If you cannot positively demonstrate to me 
that there is a dearth of anesthesiologists or care, high 
quality timely care for our veterans, if you cannot demonstrate 
that to me concretely then you are speculating. It is in the 
dictionary, dude.
    Here is the thing. If you cannot demonstrate that our 
veterans are getting high quality care in a timely manner, what 
you are saying is meaningless. I would like to see from you on 
paper a chart that shows me that our veterans are not getting 
high quality, timely care, because that is the only reason that 
we are all here. It has nothing to do with your 17 page 
biography and CV, sir.
    Dr. Harter. To be clear----
    Mr. Van Orden. It is not about status. It is not about a 
badge. It is about high quality, timely care to our veterans.
    With that I yield back.
    Dr. Harter. Can I respond?
    Ms. Miller-Meeks. Thank you.
    Mr. Van Orden. If the chair so recognizes you.
    Ms. Miller-Meeks. Mr. Van Orden, you may respond, Dr. 
Harter.
    Dr. Harter. Just to be clear, our assertion is the current 
state is that there is not a shortage of anesthesia providers. 
Therefore, making significant changes to the scope of practice 
of the nurse anesthetists, there is no compelling reason to do 
that.
    Is the question to show that there is currently a shortage 
of anesthesia providers or to show that there is not?
    Ms. Miller-Meeks. Thank you.
    The chair now recognizes Representative Kiggans.
    Ms. Kiggans. Thank you very much, Madam Chair.
    I proudly represent Virginia's 2nd congressional district, 
home to a large veteran population and active duty military as 
well. I served in the Navy myself, too, for 10 years. I am also 
a board certified adult geriatric primary care nurse 
practitioner, and I have had the privilege of taking care of 
some of greatest generation in many different care settings 
with many different care teams. I consider myself possibly a 
subject matter expert in this topic today.
    I want to start with the three things that I think that we 
can all agree with. I think that we can all agree that we have 
a healthcare provider shortage. There is not enough of us, 
right, to give the care that we need, especially in the VA 
setting.
    I think that we can all agree that no one practices in a 
silo. I know you guys talked about that, and Ms. Setnor, you 
talked about it being a team sport. I certainly think that 
healthcare is a team sport no matter where you are. Even if you 
are the only provider in a rural setting there is always 
somebody you can call. You are going to text somebody or get an 
answer to your question if you do not have that answer.
    The third thing I think that we can agree on is that VA 
healthcare has much room for improvement. I have been in 
Congress for 9 months and have sat on this Committee proudly 
and have listened time after time about veterans that come and 
different care organizations that come and tell me that VA 
healthcare is inadequate, 100 percent. We have got to do better 
for our veterans in a lot of different areas.
    I will tell you what is harmful for veterans. A couple of 
you spoke about harming veterans. What harms veterans is when 
we cannot give them the healthcare that they deserve.
    I will get off my chest just ever so briefly with Dr. 
Ehrenfeld about some of your comments about nonphysician 
providers and advanced practice nurses. They were offensive to 
me personally as someone who has worked with some of the 
greatest geriatricians in the world to take care of very 
vulnerable people. To even say that there is worse health 
outcomes for a nurse practitioner. We practice differently. We 
just do. I mean, we are educators. We are nurses. We do not 
want to be doctors. That is where I think a lot of physicians 
really get confused. We do not want to do open heart surgeries. 
We do not want to take your place. We want to partner with you. 
We need that recognition. We fight day in and day out. You talk 
about that we have higher expenses because we order more tests. 
Perhaps we are being more thorough. If you want to talk about 
expenses. We are a cheap form of healthcare. Advanced practice 
nurses, we have to fight for the pay that we get. We are not 
compensated in my opinion as much as we need to be.
    Be careful with the rhetoric that you use and the companies 
that you use it in.
    You talk about, you know, the VA and why this Committee and 
why Congress is now weighing in on this issue, this Federal 
issue. Well, that is our job; right? In Congress, we provide 
oversight, especially for Federal healthcare which is the VA. I 
know there are state standards. I sat in the State Senate for 3 
years. We argued about autonomous practice for nurse 
practitioners. During COVID, you know, it was 5 years. We had 
to practice for 5 years before we could even apply to practice 
independently. During COVID we switched it to two. After 2 
years as a nurse practitioner, 2 years of experience I could 
practice independently. During one of the most challenging 
healthcare times in our country where we invited sick people to 
come visit us, and we took care of them every day and we said 
come see us if you do not feel good. We will take care of you. 
With 2 years of experience. Then after COVID they wanted to 
switch it back to five. How can you even? Why is it different 
at different times?
    I know Ms. Setnor, you talked about on the battlefield when 
nurse anesthetists could perform the same duties. Why is it 
different? Either we are going to do it one way or we are going 
to do it another way.
    I wanted to again talk about also kind of the eyes and ears 
argument. I know we have the optometrists and ophthalmologists. 
My dad is a Vietnam veteran. He was a Green Beret. He only uses 
VA healthcare for two things. That is for glasses and for 
hearing aids and so many of my patients the same. Glasses and 
hearing aids are expensive.
    If we do not expand these care teams, you know, I have been 
a supporter of even supporting it to pharmacists. Simple 
things. Now, within scope. I think there is a discussion to be 
had about what is your scope of practice. We have got to 
acknowledge that we need to expand our care teams because we 
are struggling. Wait times, access to care, patient 
satisfaction. No, we are not there. If we do not look at some 
of the obvious answers that are in this room then we are 
failing our veterans.
    I want to yield my last few seconds to Ms. Setnor. If you 
could please in your own view, how has expansion of full 
practice authority for APRNs affected availability and quality 
of care at the VA?
    Ms. Setnor. Thank you for the question.
    One thing I would like to clarify that Dr. Murphy kept 
referring to was licensure. He never referred to our education 
and training. The education and training of CRNAs is exemplary. 
We are educated and trained to practice at the highest level. 
We are airway experts. To take care of the PACT we can do that 
easily.
    As far as expansion of care, as I mentioned to Dr. Miller-
Meeks' facility in Iowa, they have the best team care model. 
They work independently of each other and they take care of 
very sick patients. They have high acuity and they are very 
complex cases. They do it seamlessly. They have invited Members 
of Congress to come and shadow them so that they can see the 
work in progress.
    Ms. Kiggans. Thank you. My time has expired. I will yield 
back.
    Ms. Miller-Meeks. Thank you, Representative Kiggans.
    Maybe we can silence some phones, although I like the song.
    The chair now recognizes Representative Scott for 5 
minutes.
    Mr. Scott. Well, thank you. Let me get the mic on. Thank 
you very much.
    First, I want to thank Chairwoman Miller-Meeks and Ranking 
Member Brownley for allowing me to participate in this 
incredibly important hearing. And for your support for our 
fantastic veterans.
    Let me just start by saying that for over a decade, 
expanding three different administrations, I have called for 
the VA to reject any proposal that removes the medical 
expertise of physicians during intricate surgical procedures 
with our veterans. I was very pleased that after years of 
extensive review and study and at the urging of myself and 
other Members of Congress, medical organizations, veterans, and 
the veterans' family members that then-VA Secretary McDonald 
put our veterans first.
    Unfortunately, this current administration has put forth 
this proposal yet again that would replace the current method 
of anesthesia administration, meaning that complex surgeries 
could be performed without the presence of trained 
anesthesiologists. Ladies and gentlemen, we are talking about 
these surgeries being applied to our precious veterans. Of all 
groups it is our veterans that have battlefield wounds, that 
have intricate problems. If there is anybody that needs to have 
the best and most reliable anesthesiology care it is our 
precious veterans who volunteer to put their lives on the line 
on the battlefield for us. They need physicians that are 
trained with the latest information, the best talent possible.
    Now, I have great respect for our nurses. My daughter is a 
nurse at Grady Hospital in Atlanta, Georgia. I love nurses. 
They are not qualified to give the level of expertise when it 
comes to anesthesiology. That is the most important part of 
having surgery, putting our veterans to sleep so the surgery 
can be performed with the best of care. Very importantly, 
waking them up after a successful surgery. There is no more 
important thing. Don't our veterans deserve the best? All of 
our American citizens do. It would be a mockery and a hypocrisy 
if we do not perform this for our veterans. Each of you, and 
each of you on the panel, if we have to have surgery would not 
we want to make sure we have a trained physician conducting 
that basic talent that they have?
    If I may, I would like to ask a question of Dr. Harter. If 
the administration, Dr. Harter, allows this proposal, the 
Atlanta VA in my home state will move to a nurse-only care 
model while other world-class hospitals in Georgia continue to 
use the anesthesia team model. Why, Dr. Harter, should veterans 
in Georgia, or anywhere in our Nation, have a lower quality of 
care and safety than any other member of our Nation or citizen 
of our state? Dr. Harter.
    Dr. Harter. Thank you, Mr. Scott.
    Clearly we feel that there should not be a different 
standard within the VA system than for what is in the civilian 
setting for 45 states in the Nation and is used even in the 
other five states it is a very frequently used model to still 
have the anesthesiologist or physician-led anesthesia care 
team. We feel that the standard should be at least as high 
within the VA system as it is in the civilian setting.
    Mr. Scott. Well, thank you very much for that response.
    Is my time? All right. Thank you all very much.
    Ms. Miller-Meeks. Thank you, Representative Scott.
    The chair now recognizes herself for 5 minutes. Again, 
thank you all for your testimony, for being here. For those who 
served, thank you for your service, and for those who care for 
our veterans, thank you all so very much.
    Ms. Setnor, thank you for your comments about Iowa and Iowa 
VA. It is a physician-led team. The surgeon who is a physician 
is, in fact, in care in the operating room for all care. As a 
practicing physician who worked with CRNAs and have deep 
respect for them, I was, in fact, the supervising physician 
during those care and those procedures.
    I also would like to say that in my time as a faculty 
member at the University of Iowa, we had optometrists that were 
on our faculty. In my private practice in Ottumwa, Iowa, we had 
a local optometrist join us who had done an internship at the 
VA in St. Louis, and that person was a full partner in our 
practice. Not an employee and not subservient to me. However, I 
do feel that there is a difference in care. The concern that I 
have is that you will see behind me a poster.
    Dr. Barney, can you tell me what that is? Maybe we can 
raise it up.
    Dr. Barney. It is a multifocal Intraocular Lenses (IOL). It 
looks like we might have some capsular opacification. From this 
distance it is hard to tell but it looks like a multifocal IOL.
    Ms. Miller-Meeks. It is a multifocal IOL that underwent a 
Yttrium Aluminum Garnet (YAG) capsulotomy by an optometrist who 
was trained by another optometrist. The veteran was sent out of 
state to go to a state where it is under the state's licensure 
laws that optometrists can do YAG laser capsulotomies. I will 
fully admit that I have pitted an intraocular lens before. I am 
not pure. This is a multifocal intraocular lens that was 
severely pitted. It cost $20,000 to have this removed from that 
veteran in another State when they went back to their 
practicing state after they had been sent out of state by an 
optometrist. That is why this is a concern to me.
    Dr. McLeod, in your written testimony you referenced the 
team approach to eye care helps ensure patients receive the 
most appropriate treatment in a timely manner. Can you 
elaborate on the benefits of this team approach that it has for 
patients as well as for the healthcare system itself?
    Dr. McLeod. Absolutely. As we look at the healthcare 
systems, we recognize there is a full range of care that is 
required whether you are out in the community or in the VA. It 
has been referenced that, you know, that access to patient care 
is really important. When we look at the volume of cases coming 
in, having a system in place that you can adequately deal with 
eye care, adequately deal with the need for glasses and contact 
lenses, and meet those basic needs is really important. That is 
actually a huge volume.
    Beyond that we have glaucoma. We have macular degeneration. 
We have diabetic retinopathy. There is a whole series of things 
that need to be taken care of. Different people need to do 
different things. Making sure that there is an adequate 
optometric supply in order to deal with the primary eye care, 
the glasses, contact lenses actually is one of the things that 
would really help getting patients through. Once patients get 
into a disease state, having physicians that have the expertise 
to manage those diseases appropriately, to then get them to 
surgical care when necessary, to do that surgical care working 
with the optometric group allows for a system of care that is 
able to manage a given patient and a population of patients 
through the system in a timely manner with high quality safe 
care. We have to work together for this.
    Ms. Miller-Meeks. In its written statement, the American 
Optometric Association states that state regulators have made 
it clear that little or no patient complaints have resulted 
from the expansion of state optometric scope of practice laws. 
Let me also say that the physician who removed that intraocular 
lens and brought this case to me, there was no complaint 
reported, nor any lawsuit filed.
    What have you heard from ophthalmologists or other 
providers that are practicing in these states?
    Dr. McLeod. The first thing to address is there is sort of 
the misconception that it is a norm out in the community for 
optometrists to be doing laser surgery. It is not the norm. 
There are approximately 33,000 optometrists in the country. If 
you look at the total percentage that are doing the YAG laser 
capsulotomy that you reference, it is a half of 1 percent of 
the total. If you look at laser cases it is 0.1 percent of the 
total. Bringing optometric surgery into the VA with any degree 
of scale is actually a far outlier from what happens in the 
community. Then when you look at the relatively small 
percentage that we do see, unfortunately what we see is an 
overrepresentation of outcomes that we would be concerned 
about.
    Now, what you will hear is we do not have a lot of data for 
poor outcomes. Much of that is that we actually as systems of 
care do not have good systems for capturing and reporting poor 
outcomes unless it is volunteered by practitioners.
    The last point that I will make is that malpractice rates 
are not a good way of looking at whether care is good or bad. 
People do not typically get sued because they have got a bad 
outcome. They get sued because they have a poor relationship 
with an unhappy patient. You can smooth over a lot of poor 
outcomes with your relationship and that is not what we want 
for our veterans or for the American population.
    Ms. Miller-Meeks. Thank you very much. I am sure we would 
all have more questions that we would want to ask. On behalf of 
the Committee I thank you all for your thoughtful testimony and 
for joining us today.
    You are now excused, and we will wait for a moment as the 
second panel comes to the witness table.
    [Recess]
    Ms. Miller-Meeks. Welcome everyone. Thank you for your 
participation today.
    Joining us today from the Department of Veterans Affairs 
are Dr. Erica Scavella, Assistant Under Secretary for Health 
and Clinical Services and Chief Medical Officer; Dr. 
Christopher Saslo, Assistant Under Secretary for Health for 
Patient Care Services and Chief Nursing Officer; and Mr. Ethan 
Kalett, Executive Director, Office of Regulations Appeals in 
Policy.
    Dr. Scavella, you are now recognized for 5 minutes to 
deliver your opening statement.

                  STATEMENT OF ERICA SCAVELLA

    Dr. Scavella. Good morning, Chairwoman Miller-Meeks, 
Ranking Member Brownley, and distinguished members of the 
Subcommittee. Thank you for the opportunity today to discuss 
VHA's position regarding National Standards of Practice. 
Accompanying me today are Dr. Christopher Saslo and Mr. Ethan 
Kalett.
    VA is developing National Standards of Practice for 51 
occupations to ensure safe, high quality care our Nation's 
veterans and to ensure that VA healthcare professionals meet 
the needs of veterans wherever they are located. National 
standards are designed to increase veterans' access to 
healthcare and improve health outcomes.
    VA is committed to ensuring that stakeholders are engaged 
in the process to develop National Standards of Practice in 
each and every health occupation. VA has not yet finalized 
National Standards of Practice for any of the occupations. The 
National Standards of Practice will be designed through 
extensive internal and external expert consultation.
    To further engage with key stakeholders, VA has been 
hosting listening sessions in August and September 2023 for 
professional associations that are in-service organizations, 
the clinical community, the public, and Members of Congress to 
provide to VA their research, input, comments on variances 
between state licenses and scopes of practices, as well as 
their recommendations on what should be included in VA's 
National Standards of Practice.
    VA will consider all feedback received in these listening 
sessions when drafting the National Standards of Practice for 
each discipline. When the draft National Standard is ready it 
will be published in the Federal Register for public comment. 
Further, VA will send to every state board for that profession 
a letter with information on the impact of the proposed 
National Standards of Practice on the specific state with an 
opportunity for the state to respond.
    The development of National Standards of Practice will not 
undo the longstanding team-based model of care already 
established within VA that ensures competent, safe, and 
appropriate care for veterans. VA encourages a team-based 
approach to patient care. National Standards of Practice will 
support and define roles within the team regardless of state.
    National Standards of Practice are intended to strengthen 
the team-based care and thereby generate the best possible 
access and outcomes for veterans. Patients are familiar with 
the concept of having a team of caregivers, including nurses, 
physical and respiratory therapists, and others. The anesthesia 
care team can be considered a more specialized model of that 
team. CRNAs provide anesthesia care for surgery, trauma, 
procedures in nonsurgical and critical care settings, and 
chronic pain management as part of the patient care team.
    VA has a proven team-based model of care involving both 
anesthesiologists and CRNAs, as well as various additional 
types of providers, including trainees from both medical and 
nursing training programs who come to VA for its longstanding 
tradition of training excellence. The team concept relies on 
the understanding that no one provider is alone and 
unsupported.
    Team-based care relies on the knowledge and discretion of 
the facility anesthesia leadership who determine the team 
composition based on multiple factors. Major procedures 
performed at complex VA facilities such as cardiothoracic 
surgery require the expertise of both subspecialty trained 
anesthesiologists, as well as experienced CRNAs with additional 
training or experience in cardiac anesthetic management.
    More commonly performed procedures, such as screening 
colonoscopies, are completed much more widely throughout our 
system. These procedures can require careful preoperative 
evaluation, and certain patients may safely receive their 
anesthesia with a CRNA providing their principal care with 
appropriate collegial support if needed.
    In regard to the CRNA National Standards of Practice, VA 
will only include independent practice if VA determines it is 
appropriate, safe, and in the best interests of veterans. VA 
anesthesiologists and CRNAs will continue to work as a team and 
independently where appropriate to provide vital anesthesia 
care to veterans throughout the United States.
    The Temple University School of Law was contracted to 
conduct an independent, third-party comprehensive review of 
each state's licensure requirements for CRNA and analyze the 
differences in CRNA practice across the country. This data is 
now being used to develop the CRNA National Standards of 
Practice by a team of expert CRNAs and other advanced practice 
nurses and physicians. We intend to release this data in the 
coming weeks.
    In regard to the Optometry National Standards of Practice, 
VA is currently evaluating whether the National Standards of 
Practice will authorize optometrists in the 10 states that 
allow eye surgery to practice and operate within the full scope 
of their license. VA does not intend to allow VA optometrists 
who hold a license in any other State to perform laser eye 
surgery.
    We received great feedback from the listening session held 
on August 31. VA is using the information presented to 
determine what should be included in the proposed national 
standard.
    We appreciate the input of the Committee, lawmakers, and 
all stakeholders on this important issue. We are committed to 
honoring our Nation's veterans by ensuring a safe environment, 
to provide exception healthcare.
    To close, our next listening session is this Thursday on 
the 21st and will allow stakeholders invested in VA anesthesia 
care the opportunity to provide research, input, and comments 
on the variance between CRNA, State licenses, and also to 
provide recommendations on what they believe should be included 
in VA's proposed CRNA National Standards of Practice.
    VA will consider all feedback received at the listening 
session when drafting the National Standards of Practice.
    Chairwoman Miller-Meeks and Ranking Member Brownley, we 
appreciate our continued support and look forward to answering 
your questions.

    [The Prepared Statement Of Erica Scavella Appears In The 
Appendix]

    Ms. Miller-Meeks. Thank you, Dr. Scavella.
    The chair now recognizes--is Mr. Saslo talking? Excuse me. 
I am going to defer my questions to the end so the chair now 
recognizes Ranking Member Brownley for any questions she may 
have.
    Ms. Brownley. Thank you, Madam Chair.
    I just wanted to say, I wanted to have a follow-up question 
on the first panel and was unable to. I just want to make it 
clear that my concern is the VA have the same kind of standard 
that hospitals outside of the VA have. I know with physician-
led teams even in rural hospitals it was mentioned about the 
challenges in rural areas.
    Let us just take anesthesiology as an example. If there is 
not an anesthesiologist in the rural area then it will be 
physician-led or surgeon-led or something. It will be 
physician-led is my understanding. In looking at that kind of 
standard, in looking at the VA, I am hopeful that we will hold 
on to that standard to be in parity with what private hospitals 
are doing around the country.
    Having said that I wanted to ask this question around 
optometry and the ophthalmologist. The ophthalmology community, 
and you mentioned this just in your testimony about you do not 
intend on optometrists to be able to do laser surgery in states 
where it is not allowed. It sounds to me as though you are 
planning on having a two-tiered system within the standard.
    Dr. Scavella. Thank you for the question.
    When it does come to looking at any clinician's ability to 
perform the services it is based on that person's experience 
and licensure. With regard to optometrists, we do know that 
there are only 10 states currently that do train their 
optometrists to perform laser surgery. Transporting that skill 
for those individual optometrists to a location theoretically 
outside of those 10 states allowing them to do that surgery 
could potentially happen. However, we would not be looking at 
those who are not trained appropriately who have licenses in 
the other 40 states. Again, this is all under review and 
consideration based on our listening sessions, based on our 
engagement with the entities who were here today on the first 
panel. We are including all of that information as well as 
review of quality, access, and safety data to make our decision 
related to that.
    Ms. Brownley. You are intending on that judgment call to be 
made at the medical centers across the country?
    Dr. Scavella. The decision to allow a clinician to do a 
specific type of duty is based on their specific experience. 
That takes place at each medical center. I, myself, am a 
physician. My license in Maryland says physician and surgeon. I 
am not proficient in surgery. My medical center would be 
required to determine what specific skills I can provide 
regardless of what my license states. It is an individual 
decision that is based on that particular clinician. It is 
based on their skills, their experience, and also their 
clinical outcomes. We do evaluate our clinicians through a 
focused and an ongoing professional practice evaluation which 
allows us to know what we think they can do and we can see what 
they can safely do and perform for our veterans.
    Ms. Brownley. Very good.
    This is the second time that the VA has considered adopting 
a nurse-only anesthesia team. In 2016, veterans spoke out 
strongly against the proposal and more than 25,000 veterans 
commented in support of keeping anesthesiologists as the 
leaders of the team. The American Legion recently conducted a 
survey of veterans on the issue, the results of which it 
provided in a statement for the record in this hearing.
    Based on the Legion survey, most veterans believe it is 
important for their anesthesia care to be provided by physician 
anesthesiologists, and they prefer a physician to administer 
anesthesia during surgery.
    How is VA weighing the views of veterans in the development 
of the National Standards of Practice for nurse anesthetists? 
What exact criteria will be used to make the final decision?
    Dr. Scavella. Thank you for that question. I will start and 
then I will hand it to my colleagues.
    Related to the American Legion survey, we did speak with 
the director of American Legion, both during the development of 
the questions, as the information was coming back, and then we 
did receive a preview of what the findings were.
    We do understand that our veterans are committed to having 
the best care possible. We would like to continue to work with 
them to explore what that means in all different care settings.
    Regarding the ability to make a determination related to 
the type of care that they are receiving, we want to make sure 
that we are providing care that is equitable, that is 
accessible, and that is safe.
    Dr. Saslo, would you like to add anything?
    Mr. Saslo. Thank you, Dr. Scavella.
    I think it is important to also recognize that we are not 
looking, and we have said it before, we are not looking at a 
nurse-only model. We continue in looking at the team-based 
models.
    As an adult nurse practitioner, even as an independent 
practitioner in VA, my goal is to make sure that I work as part 
of a team.
    Ms. Miller-Meeks. Excuse me. Your time is up. Thank you.
    Mr. Saslo. Oh, I apologize.
    Ms. Miller-Meeks. It was up when she yielded to you so, 
which was inappropriate. Thank you.
    The chair now recognizes Representative Bergman for his 
questions.
    Mr. Bergman. Thank you, Madam Chairwoman.
    Just out of curiosity, those of you sitting on this panel 
who work at the VA. Yes?
    Dr. Scavella. Yes.
    Mr. Bergman. Then you have got the members of the first 
panel who basically do not work at the VA. They represent 
their, if you will, constituencies. Do you guys ever get 
together and just, you know, whether it be a quarterly meeting? 
Let us focus on just the AMA, because the overarching 
institution with all the subspecialties underneath it and you 
as the VA are the overarching umbrella, if you will, of all 
things veteran and veteran healthcare. Do you guys ever, I 
mean, do you have routine meetings? Could you describe one?
    Dr. Scavella. Sure. Thank you for that question, 
Congressman Bergman.
    We have been engaged with several organizations, including 
the AMA since 2021. We have dates of the over 200 engagements 
we have had with several different stakeholders.
    Mr. Bergman. Did it not occur before 2021?
    Dr. Scavella. We do but I can tell you that we have got 
dates in our files today----
    Mr. Bergman. Okay.
    Dr. Scavella [continuing]. that indicate that for this 
particular purpose that we have been engaging with the groups, 
including the AMA, since 2021.
    We do meet with these entities and I think what we are 
hearing from them is they are interested in being a part of 
the----
    Mr. Bergman. Let me ask the question. Since you do have 
gatherings has the question ever come up since 2021 that care 
in the community for veterans, has that ever been the subject 
of one of your gatherings? It is one thing to work in the urban 
suburban setting where you have the big VA medical centers and 
you have big civilian, you know, hospitals and surgery centers 
and whatever. I mean, has there ever been any focus of a 
meeting on what it means to provide rural and remote healthcare 
for veterans in this 21st century?
    Dr. Scavella. Thank you for that question.
    Yes. We have explained that in some locations, due to the 
acuity of the facility, the types of care that is provided.
    Mr. Bergman. Explaining is not dialoguing.
    Dr. Scavella. Okay. I will say during dialogs, during 
meetings with these different entities we have explained that 
we do have some concerns related to our ability to provide care 
in all locations where VA facilities or care----
    Mr. Bergman. Okay. I am just kind of curious because when 
you have stakeholders in anything, and again, I think everybody 
here in the room believes why we are here is to provide better 
outcomes for veterans in healthcare.
    Are you aware, and this is for any one of the three of you, 
are any of you aware that in the 2016 APRN final rule that VA 
stated that CRNAs provide quality care and are able to practice 
independently without added risk to patient safety?
    Mr. Saslo. Yes, we are aware of that. During that period of 
time the decision was made by the administration at that time 
not to move forward with the full practice authority for CRNAs 
only while the remainder of the advanced practice rolls were 
given the full practice authority at that time.
    Mr. Bergman. Okay. Well, since we are facing an ongoing 
shortage, workforce shortage across both VA and the private 
healthcare industry, especially in the rural and remote areas, 
how will it restrict the services that certain health 
professionals can provide instead of allowing them to provide 
the full scope of services under their license do anything to 
help the problem? Are we unnecessarily restricting?
    Dr. Scavella. I will start and then I will turn it over to 
my colleague, Mr. Kalett.
    I think we want to make sure any provision of services that 
we provide that we are providing safe care. That needs to be 
evaluated closely to make sure that we are not providing 
anything that we think is going to be potentially a poor 
outcome for our veterans. It is not an easy answer. It is not 
just a linear answer. It is based on lots of factors.
    Mr. Kalett.
    Mr. Kalett. Thanks for the question.
    The idea here for the National Standards of Practice is to 
remove barriers. If there are professions who, for example, 
require a referral before they can see a patient, like PT, 
eliminating that within the VA system would be our goal. The 
goal is not to limit top of license practice. If you have a 
license that allows you to do more than what a national 
standard can do, there could still be the way to do that. We 
are not looking to strict care if I understood your question.
    Mr. Bergman. Okay. Thank you.
    With that, Madam Chairwoman, I yield back.
    Ms. Miller-Meeks. Thank you, Representative Bergman.
    The chair now recognizes Representative Budzinski for 5 
minutes.
    Ms. Budzinski. Thank you, Madam Chairwoman.
    I appreciate the input from all stakeholders on this 
important issue. My team and I have met with numerous 
stakeholders on both sides of this issue, and I am particularly 
interested in how much of this effort will impact our rural 
veterans in particular.
    As we all know and have consistently heard, we are facing 
severe shortages of healthcare workers. Overall, and 
particularly in rural areas like those in my district, veterans 
in these areas most often travel lengthy distances for care, 
especially when seeking more specialized care. Professions such 
as CRNAs and optometrists often fill these gaps in most rural 
areas which leads me to my first question to Dr. Scavella.
    Can you elaborate on the VA's process for these standards 
and to what extent the agency is factoring rural access 
challenges into your analysis of whether health professions 
such as CRNAs and optometrists' scope of practice should be 
broadened?
    Dr. Scavella. Thank you for that question.
    Yes, making sure that all of our veterans have access at 
all the locations where we provide services is extremely 
important to us. If you cannot get the care then it does not 
matter if it is great or not. We want to make sure we are 
providing that care.
    In rural locations we may have different challenges. Even 
in some urban locations we may have different challenges with 
being able to provide the services that we need to provide. We 
are keeping that at the forefront of everything that we are 
doing.
    Dr. Saslo or Mr. Kalett, would you like to add anything?
    Mr. Saslo. I think it is really important, and I appreciate 
the question about the rurality because we recognize that every 
state has rural areas to it. Our goal really is to try to 
provide the best and the safest care. NorthStar is always at 
our forefront when we are looking at the national standards for 
all 51 professions. I think the best take home message is, yes, 
we are looking at exploring all of the opportunities as long as 
it is the national standard, not the minority of what we 
deliver in healthcare. For those states that may be a smaller 
number providing greater access, we are not looking to restrict 
those particular states but we do not necessarily want to see 
that care broadened across because it is not the norm for the 
rest of the country.
    Mr. Kalett.
    Ms. Budzinski. Okay. I wanted to mention another one of my 
top priorities since joining the House Veterans' Affairs 
Committee (HVAC) has been working to ensure veterans have 
access to comprehensive behavioral health treatment as well. 
That VA is keeping this as a focus in the development of these 
national standards. With that in mind I noted the mental health 
and suicide prevention professions that would be included in 
the list of 51 occupations for national standards.
    My question, again, I will start with Dr. Scavella, how do 
you see these national standards improving behavioral health 
access and suicide prevention efforts for our veterans?
    Dr. Scavella. Thank you for that question.
    There are several professions represented that do extend 
and perform care in our mental health or behavioral health 
settings and that are able to both extend the team that is 
providing that care and also sometimes provide that care 
specifically. We know that there are ways to expand the team by 
giving them more autonomy and ability to provide that care 
directly to veterans when it comes to suicide prevention and 
mental healthcare.
    Mr. Saslo. If I could just add to that. I think it is 
really important as Dr. Scavella pointed out that several of 
the team members we already use and we want to maximize that 
delivery such as those social workers, psychologists, and some 
of our advanced practice nurses and delivering that mental 
health that is so very vital for our suicide prevention.
    Ms. Budzinski. Would you like to add anything? Okay. I 
think I have time for one other point and question.
    I wanted to turn to quality of care. We heard during the 
first panel that quality of care may diminish under these new 
standards and both sides have cited studies that I think are 
important to factor into these proposed standards.
    I believe we do need some form of standardization but I 
also want to ensure it is done in a way that does not harm the 
quality of care for our veterans, of course.
    Can I start again with you, Dr. Scavella? In addition to 
seeking public comments through the Federal Register, what 
other steps does the VA plan on taking to ensure veterans see 
improved health outcomes with these standards?
    Dr. Scavella. Thank you for that question.
    One of the very nice things about the Department of 
Veterans Affairs is that we have lots of data. We can look at 
healthcare outcomes and compare and contrast the care that our 
veterans are receiving. We obviously can look at the quality of 
the care being provided by different clinicians by focusing on 
the work that they are doing, work they have done in the past, 
and make sure that we are rightsizing and only allowing those 
with the skills, education, and training to perform those 
duties.
    Mr. Saslo. I would like to also add that one of the things 
that we recognize as part of the National Standards of Practice 
is that we have an obligation to look at the future state. As 
we roll out those National Standards of Practice as they are 
finalized, one of our goals in VHA is to look at the quality of 
the data, the outcomes to make sure that what we are doing 
continues to have ongoing oversight. The national standards 
have to be reviewed and renewed or updated every 5 years at a 
minimum. One of our goals is that should those standards need 
to be changed sooner because we identify opportunities or 
changes in practice across multiple states, we want to be able 
to have that ability to look at them up front and be able to 
address them sooner rather than later.
    Ms. Budzinski. Thank you. I yield back.
    Ms. Miller-Meeks. Thank you.
    The chair now recognizes Dr. Murphy for 5 minutes.
    Mr. Murphy. Thank you, Madam Chair. Thank you guys all for 
coming. I just want to say from the bottom of my heart as a 
physician and a Member of Congress, I have a very, very large 
contingent of veterans in our district. I deeply appreciate 
your compassion and care for those who have severed our country 
so well.
    Just a few questions. I gave kind of my thoughts about the 
scope of practice and the creep of the scope of practice 
because everybody wants to do what everybody did before and 
vice versa. It just gets in this absolute maelstrom of what is 
happening.
    Just a side note, Dr. Scavella, do you have anything to do 
with the electronic medical record (EMR)? We had a hearing last 
week and it did not go well. Everybody was very disappointed in 
the EMR that is going on with the VA system.
    Dr. Scavella. No, sir. That is not in my portfolio.
    Mr. Murphy. Bless you. I think you are very lucky for that. 
It spoke to me when you said we have data that confirms this, 
that, and the other stuff. That was one of the purposes of the 
EMR is to cull data. If you do not have a functional one I do 
not know how you cull data really.
    I just want to kind of ask a question. Dr. Scavella, you 
noted that the VA has a plan not to move away from the team-
based model. If that is the case then tell me how you plan the 
role of the physician in that if it is team based? How does 
that work?
    Dr. Scavella. Thank you for that question.
    In VA at times there may be different members of the team 
who may be the lead of the team. We believe that the team-based 
model is important. The majority of the time it is a physician-
led team but there could be times where the physician may not 
be part of that team. We are being broad with that terminology 
to make sure that we are able to be agile with the care we are 
providing.
    Mr. Murphy. Yes.
    Dr. Scavella. If there is something that requires a 
physician, a physician. We want to make sure that we leave 
ourselves some room for that.
    Mr. Murphy. Sure. All right. Well, thank you.
    I agree with you completely. A physician does not have to 
be at everything all the time. The bottom line is we want to 
take good care of our veterans. I mean, I think that is, 
absolutely everybody agrees in the room. I said this before, 
and I will say it again. That is the bottom line.
    Can you describe to me what the problem is that is trying 
to be solved?
    Dr. Scavella. Yes, sir. Thank you for that question as 
well.
    We want to make sure that if we have veterans who are 
entering our system in locations where we may not have the full 
complement of a team, that those people who are trained and 
competent in the needs of that patient, that they are able to 
provide that care.
    Mr. Murphy. Okay.
    Dr. Scavella. That is the ultimate.
    Mr. Murphy. Sure. Sure. I understand that completely.
    Where does Community Care fit in with that? I take care of 
VA patients. When I was running a practice we were part of the 
Community Care system. You know, I have a VA clinic that is 
literally 800 yards from the main medical center.
    Where does Community Care fit in that model? My question 
really centers around are you going to send somebody out in the 
community that already has established scope of practice, 
residency physician that has a fully recognized, fully 
established expertise in that field? Or are we going to just 
try to keep them within the VA where their expertise and their 
scope of practice is not uniform satisfied within the country?
    Dr. Scavella. To answer the question related to how we are 
going to use Community Care, if we place a referral, our intent 
is always to see what our availability is within our system. We 
need to look at both the time length for the appointment 
between the time desired and the time necessary for the patient 
to be seen, as well as how far they may need to travel for that 
care.
    There are two different decision points when it comes to 
looking at how we get patients seen within our system or within 
the community. Those have to be evaluated each time to make 
sure that we are providing that care.
    We also use the technology that we have existing currently 
to determine if we are able to provide that care face to face 
or virtual if appropriate. Those are also factored into our 
decisions related to making referrals, and we want to make sure 
that we are doing what is best for the veteran.
    Mr. Murphy. Okay. Again, we want the best care for the 
veteran regardless of really what that looks like. In the world 
of telehealth, in the world of Community Care, I do not think 
we need to degrade the care of our veterans in the term of 
``access.'' I live in a very rural area, very rural. We do not 
need to do that.
    I get concerned, and I will just kind of say this for the 
record. Actually, I probably will not. Thank you. I will be 
quiet. Thank you all.
    Ms. Miller-Meeks. Thank you, Dr. Murphy.
    The chair now recognizes Representative Landsman for 5 
minutes.
    Mr. Landsman. Thank you, Madam Chair.
    I want to thank Dr. Murphy for his comments about the 
commitment and what you all do for veterans. Oftentimes, we 
overlook that in hearings where we want to get into the work, 
which is obviously really important, but I really appreciated 
the fact that that is something we all believe which is how 
hard you all work and why that matters so much.
    Just two questions and then I will let you all answer them 
as you see fit. One is on the listening sessions. Just sort of 
next steps, what to expect, what we should be looking out for. 
Will there be more? What do you hope to achieve and really just 
what are the next steps there?
    The second question has to do with this larger point about 
making sure veterans get the best care possible, which is 
obviously the goal that we all share. We have competing 
thoughts; right? Folks from different communities are weighing 
in. Bringing them together to think through this seems pretty 
important to me. I know that has been brought up, but you know, 
thoughts on that. How that works? How has that not worked? You 
know, getting them in a room to say, okay, you know, we all 
share the same goal of trying to provide the best possible 
care. How do we do this together?
    Dr. Scavella. Thank you for those questions.
    For the first one I will start and then I will share with 
Mr. Kalett.
    We have held four listening sessions for the National 
Standards of Practice. We have broken up the groups of which 
entities were included. Over the past 4 weeks, all on 
Thursdays, the last one that is currently scheduled we 
scheduled for this Thursday. They have been really impactful. I 
think eye-opening to all of us on this panel. We think the 
information gathered, because people have brought data, 
presentations and other things to us, I think that has been 
really important and impactful to us.
    I will turn it over to Mr. Kalett for some more details on 
how we have done.
    Mr. Kalett. Thank you. Am I on now? There we go. Sorry 
about that.
    After the listening sessions, the final one is scheduled 
for Thursday. That will the CRNA one. We expect to get a lot of 
information as a result of that listening session. We are going 
to need time to digest that information. We will then publish 
something in the Federal Register. Notices to all the states. 
We have provided your staff with a detailed high level version 
of the process.
    After we get information from the proposals where people 
tell us what they think we got. Hopefully, something we got 
right and what we did not get right. We will then have to 
finalize the standard, publish it, and that is not where it 
ends. Right?
    Once we do that we are going to move to implementation. We 
are going to have a live link where we are hoping states will 
make sue of it if they notice for what ever reason during the 
process that they are unable to get the information to us that 
they felt we needed, they will do that.
    I did want to also just address very quickly the why behind 
this because several of you have asked about that. Most 
professions are not going to experience a change as a result of 
the National Standards of Practice. That sort of leads you to 
ask, well, then why are you doing it? The reason we are doing 
it is because those professions where there are slight 
variances, administrative headaches that were noted as far back 
as the 1990's by the National Academy of Science. That is a 
problem for us. Things like requiring referrals. Or not 
allowing people to order studies. Like chiropractors cannot 
order imaging studies. These are the types of things. Or 
audiologists to dispense hearing aids. This is really the 
target of the NSPs. The bigger picture issues exist but they 
are not the prime driver for why we are doing this.
    Dr. Scavella. To continue to answer your second question 
which is related to how we can better bring together the 
groups, especially the opposing groups, I think our challenge 
has been internally within our groups, especially the two 
corollaries that are represented here. Between our 
ophthalmologist and our optometrist, internally they both align 
under me. I brought them together from day one. They have been 
part of this process. They may or may not be members of these 
organizations and may or not be representing the organizations 
in their thought processes but they have been together 
developing these standards from day one. Within our 
organization, anesthesia care, the anesthesiologists sit under 
me. The CRNAs sit under Dr. Saslo. From day one they have 
worked together to put this together. Whether they represent an 
internal VA professional group or one of these external 
entities represented today, they have been part of this 
process. I think our challenge remains and the fact that we are 
not necessarily as agile and as able to engage the presidents 
of organizations and to embed them in this work. We will need 
to work on how better to do that.
    Mr. Landsman. Thank you very much, all three of you. I 
yield back.
    Ms. Miller-Meeks. The chair now recognizes Representative 
Van Orden for 5 minutes.
    Mr. Van Orden. Thank you, Madam Chair.
    Apparently, discretion is not the better part of valor so I 
would like to yield to my colleague, Mr. Murphy, as much time 
as he requires to say something that he will later regret.
    Ms. Miller-Meeks. The chair now recognizes Mr. Murphy.
    Mr. Murphy. Not at all. I only open my mouth to change 
feet.
    I will just say this very quickly. Right now in the state 
of California, three nurse practitioners are suing the state so 
that when they interview their patients they can be called 
doctor. It is very confusing, and this is one of my major 
concerns about scope creep as it is. I do not think that is 
fair. I do not think it is right. I think it is inaccurate and 
I honestly do not think most nurse practitioners would agree 
with them. That said, it is just something that I think we have 
to be wary about of marching up the stream when there is so 
much of this scope creep. This really concerns me. I do not 
think that is accurate. I do not think it is fair. There is a 
difference between being a doctor and having a doctorate. Thank 
you.
    With that I will yield back.
    Ms. Miller-Meeks. The chair now recognizes Representative 
Van Orden for the remainder of his time.
    Mr. Van Orden. Thank you, ma'am.
    Mr., it is Kalett; is that correct?
    Mr. Kalett. Yes, sir.
    Mr. Van Orden. First of all, thank you very much for 
coming. Dr. Saslo and Scavella. It is interesting that Dr. 
Murphy and I are both struggling to read your names and we are 
talking about optometrists.
    Are there plans in place, and this is across the board, are 
there plans in place for in extremis situations? Some of us are 
from the Midwest, including the chairwoman. Suppose there is a 
snowstorm or a blizzard and the anesthesiologist cannot get to 
the hospital. Is that veteran going to be able to get medical 
care promptly?
    Dr. Scavella. Thank you for that question.
    Our goal is to make sure that we are there to provide the 
care wherever a veteran may come into the system. Whether there 
is a snowstorm or not. Perhaps I misunderstood your question.
    Mr. Van Orden. Well, ma'am, I live in a very rural area. We 
may only have one of the healthcare providers that are going to 
meet your national standard of care. I am just going to say 
that right now. It is going to happen. If we have one 
anesthesiologist who gets snowed into their house or drive off 
the road and in a ditch in a blizzard--it happens every 
winter--will the veteran that is at the hospital waiting for 
surgery be able to get that care in a timely manner?
    Dr. Scavella. I will yield to Dr. Saslo.
    Mr. Saslo. I think it is important to recognize that 
whether it is a snowstorm, or a hurricane, or an earthquake, 
one of the things that we try to make sure facilities recognize 
is how they prepare their staffing models in order to be able 
to meet the demands of the veterans when they are coming in. 
Should those types of events occur, how do we make sure that we 
are maximizing the care delivery to that veteran. It really 
will be dependent upon the facility to prepare the right model 
in order to make sure that they are meeting the needs 
regardless of the issues that arise.
    Mr. Van Orden. Well, I understand that, sir. You know, 
rocks are heavy, trees are made of wood, and gravity is real. 
We have got one anesthesiologist. If there is a qualified nurse 
anesthetist who is on station and the anesthesiologist is in a 
ditch, will he or she be able to give the appropriate medical 
care to that veteran in a timely manner? It is a very, very 
simple questions.
    Dr. Scavella. Yes. It depends. Unfortunately, it does 
depend. If the one sole anesthesia provider that is available 
is not capable of providing the care that is provided it would 
not be something that we would want to see. We would want to 
make sure that that veteran is receiving the appropriate care 
from a clinician that can provide it. In those instances it may 
be a matter of delaying the procedure. If it is elective, it 
may be a matter of sending him to another facility where there 
is the appropriate care that could be provided. It could be a 
matter of waiting if it is elective. If it is an emergency 
there is a different situation.
    Mr. Van Orden. Doctor.
    Dr. Scavella. Yes.
    Mr. Van Orden. Ma'am, may I ask where you are from?
    Dr. Scavella. I grew up in Chicago, Illinois.
    Mr. Van Orden. Okay. You have been in a blizzard.
    Dr. Scavella. Correct.
    Mr. Van Orden. Okay. I want my hair to grow back. It is not 
happening.
    I am asking you a real simple question. We have a qualified 
nurse anesthetist on station. You cannot send somebody to 
another facility because there is not one where I live. Or it 
is 60 miles away and it is 35 degrees below zero and you are in 
a snowstorm. You physically cannot move. You have got a patient 
and a qualified nurse anesthetist on station. The 
anesthesiologist is in a ditch. Will that man or woman who is 
qualified as a nurse anesthetist be able to provide adequate 
healthcare, excuse me, timely healthcare to that veteran, yes 
or no?
    Dr. Scavella. Congressman Van Orden, your key word is 
``qualified.'' If that entity is qualified----
    Mr. Van Orden. Back it up. Sorry, go ahead?
    Dr. Scavella. If that person is qualified to provide the 
care that is being requested and needed then that person would 
be able to provide that.
    Mr. Van Orden. A qualified nurse anesthetist will be able 
to administer anesthesia to a veteran in extremis without 
direct supervision, or supervision, even a phone call because 
someone is still at work, in extremis?
    Dr. Scavella. Again it depends on the care that is being 
provided and it would be a case by case basis. Sorry that I do 
not have a better answer but to give a blanket authorization to 
provide care just because you have a body does not necessarily 
mean that you can. The same thing for an anesthesiologist or a 
physician.
    Mr. Van Orden. Yes, ma'am. I understand that.
    My time is expired. I want to say one more thing. I believe 
that this model may be too rigid and there must be things 
written in here to provide for that exact scenario, because it 
is going to happen in Dr. Miller-Meeks' district just as mine.
    Thank you. I yield back.
    Ms. Miller-Meeks. Thank you, Representative Van Orden.
    The chair now recognizes Representative Scott if he wishes 
to have questions for 5 minutes.
    Mr. Scott. Yes, I would. Thank you very much once again, 
Chairwoman Miller-Meeks and Ranking Member Brownley for your 
kindness in allowing me to be a part of this.
    Ladies and gentlemen, we are at a very critical moment in 
time in our Nation's history. The way we care and express 
publicly about our thoughts, our feelings, for two groups. One 
group is our veterans. No other group is having the massive 
suicide rates as our veterans. A large percentage of those 
suicides come from inadequate healthcare in our VA system. Now 
with this movement to try to now turn over the basic element of 
medical treatment away from the doctors of anesthesiology to 
the nurses. Think about that.
    The other group are our law enforcement who put their lives 
on the line. Both groups out there willing to pay the ultimate 
sacrifice for our protection and our growth. They are worried 
about what we are discussing here today, their healthcare.
    Now, I want to direct my questions this time to both Dr. 
Scavella. I hope I got that right. Dr. Saslo. If you could 
answer these questions.
    The VA's previous process was transparent and it included 
all stakeholders. It resulted in the right decisions for our 
veterans. However, this current process lacks any transparency. 
A small work group has been tasked with working on this 
proposal all behind closed doors.
    My question to you is this. Why is this process so 
secretive?
    Dr. Scavella. Thank you for the question, Congressman 
Scott.
    We have been including our individual specialists in the 
area of each of the 51 occupations on the working group. We 
have been engaged with stakeholders since 2021 related to this 
specific work.
    Mr. Scott. Well, let me ask you this. What assurances do we 
have that the work group includes subject matter expertise from 
all key stakeholders, including front line VA 
anesthesiologists?
    Dr. Scavella. Thank you for that question as well.
    We have included our frontline anesthesiologists and CRNAs 
as well as other advanced practice nurses and physicians 
specifically for the work that is beginning for the National 
Standards of Practice related to anesthesia care.
    Mr. Scott. Well, let me ask you this. Can you and Dr. 
Scavella I believe. Did I get that right?
    Mr. Saslo. I am Dr. Saslo but that is all right.
    Mr. Scott. I do not, okay, I do not want your colleague to 
have to be by herself in answering these. This is important. 
The eyes of the Nation are on us and finally we are dealing 
with this issue of veterans.
    Answer me. Can you list, either of you, who currently 
serves on the work group?
    Mr. Saslo. Thank you for the questions.
    I think it is really important to recognize that with each 
of the different 51 professions that we are working with we 
have multiple professions within that group that are sitting on 
those workgroups. We also go back to those workgroups as they 
are developing because the concept of it as a small workgroup 
is not necessarily as accurate as it might sound. The larger 
workgroups of those particular professions are the ones 
responsible to come in and work with us to identify what 
opportunities for standardization exist amongst each of the 
professions. We hope that it is a much bigger participation 
than what you may have already been alluding to. Thank you.
    Mr. Scott. Well, my time is up. Once again, thank you very 
much. I appreciate this.
    We have a bill going forward to make sure we keep our 
anesthesiologists as the primary source for treatment in this 
area. I appreciate you all having me as a guest. Thank you very 
much. Thanks to the panel.
    Ms. Miller-Meeks. Thank you, Representative Scott.
    The chair now recognizes herself for 5 minutes.
    The reason we are having this hearing is actually because 
of comments that you have made, Dr. Scavella. We are having 
this hearing because multiple groups approached members of HVAC 
with complaints that National Practice Standards were being 
developed and they did not have access, nor were they 
communicated. Not in email, not in phone calls, not in 
meetings. We had a roundtable in April as Ranking Member 
Brownley mentioned and we found further at that roundtable that 
Allied Health professionals are nonphysician health 
professionals. To be clear, I do not consider an optometrist a 
physician. I will ask a question about that in a moment. 
However, we found that nonphysician groups had great access to 
the VA but physician groups did not. You specifically defended 
yourself by saying ``within our organization.''
    Let me just say, when you are an employee of an 
organization, which I have been, both in my 24 years in the 
military and as a physician-employee of a hospital, and as a 
nurse of a hospital, you are sometimes muted in your responses 
because you are talking to your employer. If you feel your 
employer wants to go down a certain track or pathway, you may 
not relay your true concerns or feelings.
    The other thing that I would like to mention is something I 
think that gets confused. It is often brought up in scope of 
practice issues within states and state government, is that 
often the rationale for expanding scope of practice is so 
individuals get care in rural areas.
    As we found when Oklahoma passed their laser law for 
optometrists, looking at Centers for Medicare and Medicaid 
Services (CMS) data, the majority of laser procedures were 
guess what? They were not performed in rural areas. They were 
performed in the metropolitan areas of Tulsa and Oklahoma City. 
That exists to this day.
    Can you tell me how many VA hospitals are located in rural 
areas? How many are in rural areas?
    Dr. Scavella. Chairwoman Miller-Meeks. Thank you for the 
question. I would actually have to look at a map and count. I 
do not have a breakdown of those that are specifically in those 
locations.
    Ms. Miller-Meeks. They may be in rural states but in a 
rural areas of a state. In Iowa, our two VA hospitals are in 
Iowa City, where the University of Iowa is located, and in Des 
Moines. There are not any facilities in a rural area. There may 
be clinics. If, as you alluded, if you were to allow an 
optometrist licensed in Alaska as Dr. Barney said he is 
licensed in Alaska and can perform laser procedures to then 
come and be located to the VA Hospital in Iowa, even though 
there are ophthalmologists, that optometrist would then be 
allowed to perform a procedure for which he is not licensed to 
do in Iowa. Is that correct? I think that is what you stated.
    Dr. Scavella. Theoretically, just like my license is 
transportable across the country, I can operate in any Federal 
location, potentially, if we were to make that decision that 
would be something that we would look at for quality reasons, 
potentially.
    Ms. Miller-Meeks. Which is why it is tremendously 
concerning.
    Dr. Scavella, are nonphysician providers required to 
identify themselves as such to veteran patients? How does the 
VA educate veterans as to the qualifications? When a veteran, 
or for that matter the public hears doctor or physician, they 
think that this is someone that has gone to medical school. Are 
you going to inform veterans that the person treating you has 
not gone to medical school, has not done a residency, is not 
board certified? In fact, to get on the insurance of most 
health insurance providers and Medicare, you have to be board 
certified or board eligible. Are CRNAs, are optometrists, are 
other Allied Health professionals that you may increase their 
scope of practice to practice in a state for which they are not 
licensed to do that, are they board certified and board 
eligible?
    How is it that you intend to, number one, address what the 
American Legion said when they would prefer to have a 
physician; and how are you going to use lower educated, lower 
trained providers in lieu of having someone go out into a 
community for care when there is a provider that is a physician 
provider in that community?
    Dr. Scavella. Thank you for that question.
    We would always want to make sure we were providing the 
highest quality care for the veteran and the needs the veteran 
was having at that time.
    Related to how clinicians identify themselves to veterans, 
it is our understanding that they introduce themselves, explain 
where they are as part of the care team.
    Ms. Miller-Meeks. Which is exactly why we are having this 
hearing and exactly why as a nurse married to a nurse, as a 
doctor, as a veteran, I am concerned about the secrecy. Thank 
you, Representative Scott. The secrecy of the VA in going 
through this procedure. Their lack of engagement with other 
groups and other providers until you have an open comment.
    I know that you are having listening sessions. I thank you 
for doing that but I would say that my concerns have not been 
allayed that we will be providing our veterans the highest 
quality care by care teams led by physicians, and that patients 
know whether or not a physician is delivering care or another 
individual of other education and training as knowledgeable as 
those individuals may be. I have great respect for everyone in 
the healthcare profession but I am very concerned about what is 
going on.
    The chair would recognize Ranking Member Brownley for any 
closing remarks.
    Ms. Brownley. Thank you, Madam Chair.
    I will say I served in the California legislature and 
whenever there was a Committee hearing on scope of practice and 
licensing you always knew it because there were crowds of 
people outside of the hearing room that could not get into the 
hearing room. There was a lot of debate going on outside of the 
hearing room. I know that these are very, very difficult. Very, 
very difficult issues to settle on.
    I will say that based on this hearing I feel as though we 
are getting closer to better clarity from the VA on whether a 
team-based model of care means a physician-led team-based model 
of care.
    I think the answer from the VA was most of the time. Most 
of the time it will be a physician-led model of care.
    I will say in regards to that when we compare the VA to 
those hospitals outside of the VA that is not their model of 
care. I do not want to give up quality under any circumstance. 
I think we heard also today that even in rural hospitals, and I 
think Dr. Miller makes his point of there are no hospitals in 
rural areas is a very good one. Even in those rural hospitals, 
if they are there we have been told that it is always a 
physician-led care team. It might not be the anesthesiologist. 
It might not be the ophthalmologist. It is a physician-led 
team.
    I do not want to give up quality, and I do not want to be 
less than what other hospitals are doing outside of the VA.
    I will say again what I said in my opening comments and 
that is to why the VA is doing this initiative when at the end 
of the day the medical professionals at each medical centers 
will ultimately make these decisions.
    Now, the VA said we still have to settle some of these 
discrepancies between different practices. At the end of the 
day it is still going to be the medical centers and the 
professionals they are in who will ultimately make final 
decisions on who will be performing what and scope of practice.
    The VA has also said we need more agility. I understand 
that. Even when the VA provided more flexibility of scope of 
practice during COVID, the VA has told me unequivocally that 
the practices and protocols never changed regardless of the 
emergency. Even when they were given that ability to be more 
agile it was not utilized. I have to assume that those 
decisions were based on the quality of care.
    I will just end by saying I think what other members have 
said on the Committee is the VA should never give up, ever give 
up on delivering the highest quality of health care. Our 
veterans have complex health issues and they should receive the 
highest quality of care. They should deserve no less. This is 
what we owe our veterans. I hope as we proceed in the process 
of this that we will keep the highest standard of care.
    I yield back.
    Ms. Miller-Meeks. Thank you, Ranking Member Brownley.
    I would like to thank everyone for their participation in 
today's hearing and for the productive conversation.
    I know this is a challenging topic. I have been involved in 
it at the state level, as well as here at the Federal level. 
The passion for your work and your care for veterans is evident 
to us in both of our panels.
    I appreciate everyone's willingness to come here today and 
to focus on what should be our utmost priority of putting 
veterans first.
    It is important to me and to my colleagues on both sides of 
the aisle that all veterans seeking care in the VA are ensured 
quality care that is safe and effective. I look forward to 
continued work on this effort to create equitable standards of 
practice across the VA, within the department, stakeholders and 
my colleagues on this Subcommittee.
    I will echo again that the nature of care in rural areas 
when it comes to a VA hospital facility needing providers is 
very different than what it is within a state or a district. I 
would also like to say that the workforce shortage that has 
been mentioned, last year we passed a bill to increase the pay 
for nurses, nurse practitioners, PAs, and Allied professionals 
because there was a shortage of those. I think to proffer an 
idea that there is a physician shortage so we need to replace 
them with others would be inaccurate.
    I am also going to echo a statement often made by VA 
officials, that the veteran population is unique. They tend to 
have more complex health issues with multiple comorbidities 
resulting in a higher risk of complications. Let us not forget 
that when considering policies that may have a significant 
impact on the care they receive. Let us also remember that we 
have a mission act and Community Care to address some of the 
issues in where veterans can receive care and in a timely 
fashion.
    The complete written statements of today's witnesses will 
be entered into the hearing record.
    I ask unanimous consent that all members have 5 legislative 
days to revise and extend their remarks and include extraneous 
material.
    Hearing no objection, so ordered.
    I thank the members and the witnesses for their attendance 
and participation today. This hearing is now adjourned.
    [Whereupon, at 12:28 p.m., the subcommittee was adjourned.]
   
=======================================================================


                         A  P  P  E  N  D  I  X

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


                    Prepared Statements of Witnesses

                              ----------                              


                 Prepared Statement of Jesse Ehrenfeld

    The American Medical Association (AMA) appreciates the opportunity 
to submit the following statement to the U.S. House of Representatives 
Committee on Veterans Affairs Subcommittee on Health as part of a 
hearing concerning the ``VA's Federal Supremacy Initiative: Putting 
Veterans First?'' The AMA commends the Committee for focusing on this 
critically important issue since it is imperative that our Nation's 
veterans receive the best health care possible.
    ``The Veterans Health Administration (VHA) is the largest 
integrated health care system in the United States, providing care at 
1,298 health care facilities, including 171 VA Medical Centers and 
1,113 outpatient sites of care of varying complexity (VHA outpatient 
clinics) to over 9 million Veterans enrolled in the VA health care 
program.'' \1\ Since the VHA is such a large health care system, the 
actions it takes, especially in terms of the scope of practice of its 
non-physician providers, could have an immense impact on health care in 
its entirety. National Standards of Practice developed by the VA 
Federal Supremacy Project would override long-established state laws 
governing scope of practice and health-professional licensure, and, as 
such, the quality of care provided to our veterans, and potentially 
patients across the nation, will decline if the Project is fully 
implemented. We therefore oppose the implementation of the Federal 
Supremacy Project. At the very least, we urge Congress to ensure that 
physician-led team-based care is maintained and that physician 
representation on all the Work Groups, not just the Physician Work 
Group, be mandatory.
---------------------------------------------------------------------------
    \1\ https://www.va.gov/health/
aboutvha.asp#:8:textThe%20Veterans%20Health %20Administration 
%20(VHA,Veterans %20enrolled %20in %20the %20VA.

The VA Federal Supremacy Project: Physician representation is necessary 
---------------------------------------------------------------------------
across all stages and Work Groups.

    In November 2020, the VA published an interim final rule entitled 
``Authority of VA Professionals to Practice Health Care.'' \2\ The 
interim final rule was issued to expand health care professionals' 
scope of practice ``notwithstanding any State license, registration, 
certification, or other requirements . . . This rulemaking also 
confirm[ed] VA's authority to establish national standards of practice 
for health care professionals which will standardize a health care 
professional's practice in all VA medical facilities.'' \3\ By invoking 
the Supremacy Clause of the Constitution to preempt state laws to 
develop National Standards of Practice, the VA is making it harder to 
oversee the practice of medicine and is potentially allowing non-
physicians to perform procedures that are outside the scope of their 
knowledge and state licensure.
---------------------------------------------------------------------------
    \2\ https://www.federalregister.gov/documents/2020/11/12/2020-
24817/authority-of-va-professionals-to-practice-health-care#p-65.
    \3\ Id.
---------------------------------------------------------------------------
    Based upon this interim final rule, the VA has begun the process of 
implementing National Standards of Practice for 48 health care 
occupations through the ``Federal Supremacy Project.'' As noted in the 
rule, this Project preempts state scope of practice laws and creates a 
single set of practice standards for all VA-employed physicians, and 
separate standards for 47 other non-physician health care 
professionals. The VA has already closed the comment period for Blind 
Rehabilitation Specialists, Ophthalmology Technicians, 
Kinesiotherapists, Therapeutic Medical Physicists, Registered Dietitian 
Nutritionists, Orthotists, Prosthetists, and Prosthetist-Orthotists, 
Histopathology Technologists, and Cytotechnologists.\4\ Moreover, 
comment periods are currently open for Art Therapists, Dance/Movement 
Therapists, Drama Therapists, Music Therapists, and Recreation 
Therapists and close on September 26, 2023. Finally, the VA is 
currently hosting five listening sessions to allow individuals to 
provide input on state variances for health care occupations for the 
occupations that have not yet had their feedback period closed, 
including Optometrists, Nurse Practitioners, Physician Assistants, and 
Pharmacists.\5\
---------------------------------------------------------------------------
    \4\ https://www.va.gov/STANDARDSOFPRACTICE/providing-feedback.asp.
    \5\ https://www.federalregister.gov/documents/2023/08/14/2023-
17309/announcement-of-public-listening-sessions-to-inform-vas-
standards-of-practice.
---------------------------------------------------------------------------
    Physician-led, team-based care is the gold standard of health care 
and the predominant model of care for many, if not most, of these 
occupations across the country. As such, due to the physician's unique 
role as head of the care team, it is important that physician input is 
received and implemented within the Project as early as possible. 
Importantly, physician representation on all the Work Groups, not just 
the Physician Work Group, should be mandatory since it could help to 
counter internal and external resistance when National Standards of 
Practice are published in the Federal Register for comment and help to 
ensure that these standards are accurate and built to help enforce 
team-based care. Therefore, if the VA persists in moving forward with 
the Federal Supremacy Project, we urge the VA to require physician 
representation on all Work Groups and consultation with relevant 
physician specialty societies and other internal and external 
stakeholders.

Scope of Practice: Physicians should be the head of the care team to 
ensure the highest quality care for our nation's veterans.

    Should the VA move forward with the Federal Supremacy Project, the 
AMA is concerned that the National Standards of Practice for non-
physician providers developed by the Project may not accurately reflect 
the skills acquired through the education and training of such 
occupations and may allow non-physicians to provide services and 
perform procedures that are outside the scope of their knowledge and 
licensure. The AMA strongly supports the team approach to patient care, 
with each member of the team playing a clearly defined role as 
determined by his or her education and training. While we greatly value 
the contribution of all non-physicians, no other health care 
professionals come close to the education and training that physicians 
receive.
    With more than 12,000 hours of clinical experience, physicians are 
uniquely qualified to lead health care teams. Non-physicians such as 
physician assistants, nurse anesthetists, pharmacists, and optometrists 
do not have the same rigorous and comprehensive education as 
physicians. For example, physician assistant programs are two years in 
length, require 2,000 hours of clinical care, and have no residency 
requirement.\6\ Similarly, nurse anesthetists complete only two-to-
three years of graduate level education and have no residency 
requirement. Pharmacists are trained as experts in medication 
management but have very limited direct patient care experience and are 
not trained to independently diagnose and treat patients. Students of 
optometry rarely complete postgraduate education and are trained in 
primary eye care. They are not exposed to standard surgical procedure, 
aseptic surgical technique, or medical response to adverse surgical 
events. In short, the educational programs undergone by non-physicians 
do not prepare them to develop clinical judgment or skills similar to a 
physician. For this reason, physicians and non-physicians are not 
interchangeable on a care team.
---------------------------------------------------------------------------
    \6\ https://www.ama-assn.org/system/files?file=corp/media-browser/
premium/arc/ama-issue-brief-independentnursingpractice.pdf.
---------------------------------------------------------------------------
    But it is more than just the vast difference in hours of education 
and training, it is also the difference in rigor, standardization, and 
comprehensiveness of medical school and residency programs, compared to 
other non-physician programs. To be recognized as a physician with an 
unlimited medical license, medical students' education must prepare 
them to enter any field of graduate medical education. During medical 
school, students receive a comprehensive education in the classroom and 
in laboratories, where they study the biological, chemical, 
pharmacological, physiological, and behavioral aspects of the human 
condition. This period of intense study is supplemented by two years of 
patient care rotations through different specialties, during which 
medical students assist licensed physicians in the care of patients. 
During clinical rotations, medical students continue to develop their 
clinical judgment and medical decision-making skills through direct 
experience managing patients in all aspects of medicine. Following 
graduation, students must then pass a series of examinations to assess 
a physician's readiness for licensure. At this point, medical students 
``match'' into a three-to-seven-year residency program during which 
they provide care in a select surgical or medical specialty under the 
supervision of experienced physician faculty. As resident physicians 
gain experience and demonstrate growth in their ability to care for 
patients, they are given greater responsibility and independence. This 
level of education and training is necessary to develop the acumen 
required for the independent practice of medicine, including diagnosing 
and treating patients, performing eye surgery and administering 
anesthesia.
    There is deep concern that the VA removing scope of practice 
safeguards will allow for non-physician practitioners who have not been 
adequately trained to provide medical care or perform procedures that 
are outside the scope of their expertise and licensure, ultimately 
leading to a lower standard of care for veterans. Veterans are an 
extremely complex patient population. Consequently, our veterans 
deserve better--they deserve and have a right to have physicians 
leading their health care team.

Increased Cost and Decreased Quality: Increasing non-physician 
practitioners' scope of practice within the VHA increases cost and 
decreases the quality of health care.

    There is strong evidence that increasing the scope of practice of 
non-physicians in the VA results in higher costs and worse outcomes for 
veterans' health care. For example, a high-quality study published as a 
working paper by the National Bureau of Economic Research in 2022 
compared the productivity of nurse practitioners and physicians (MDs/
DOs) practicing in the emergency department using Veterans Health 
Administration data. The study found that nurse practitioners use more 
resources and achieve worse health outcomes than physicians. Nurse 
practitioners ordered more tests and formal consults than physicians 
and were more likely than physicians to seek information from external 
sources such as X-rays and CT scans.\7\ They also saw worse health 
outcomes, raising 30-day preventable hospitalizations by 20 percent, 
and increasing length of stay in the emergency department. Altogether, 
nurse practitioners practicing independently increased health care 
costs by $66 per emergency department visit.\8\ The study found that 
these productivity differences make nurse practitioners more costly 
than physicians to employ, even accounting for differences in 
salary.\9\ The authors estimate that continuing to use the current 
staffing allocation of nurse practitioners in the emergency department 
results in a net cost of $74 million per year, compared to staffing the 
emergency department with only physicians. Not only does the increased 
resource use by nurse practitioners result in increased costs and 
longer lengths of stay, but it also means patients undergo unnecessary 
tests, procedures, and hospital admissions.
---------------------------------------------------------------------------
    \7\ Productivity of Professions: Lessons from the Emergency 
Department, Chan, David C. and Chen, Yiqun, NBER, Oct. 2022.
    \8\ Id.
    \9\ Id.
---------------------------------------------------------------------------
    This study is a uniquely high-quality study within this body of 
literature because it measures nurse practitioners working within the 
VHA system during a time when nurse practitioners were authorized to 
practice without physician supervision. It also uses a high-quality 
causal analysis. While the VA national standards of practice do not 
include nurse practitioners, this study is informative as the VA 
considers expanding the scope of practice of other non-physician 
practitioners, including physician assistants. In short, education and 
training matters. The authors note that these findings may reflect 
poorer decision-making by nurse practitioners based on their lower 
level of skill compared to physicians--causing them to seek additional 
sources of information. While it is appropriate for nurse practitioners 
to seek additional information when they are unsure or unable to make a 
differential diagnosis and determine the appropriate course of 
treatment, this path results in increased costs to the system and worse 
patient outcomes, ultimately a lower quality of care for veterans.
    These findings are consistent with other studies as well, including 
a recent study from the Hattiesburg Clinic in Mississippi which found 
that allowing physician assistants and nurse practitioners to function 
with independent patient panels in the primary care setting resulted in 
higher costs, higher utilization of services, and lower quality of care 
compared to panels of patients with a primary care physician. 
Specifically, the study found that non-nursing home Medicare ACO 
patient spend was $43 higher per member, per month for patients on a 
nurse practitioner/physician assistant panel compared to those with a 
primary care physician. Similarly, patients with a nurse practitioner/
physician assistant as their primary care provider were 1.8 percent 
more likely to visit the ER and had an eight-percent higher referral 
rate to specialists despite being younger and healthier than the cohort 
of patients in the primary care physician panel. On quality of care, 
the researchers examined 10 quality measures and found that physicians 
performed better on nine of the 10 measures compared to the non-
physicians.
    Other studies further suggest that physician assistants and nurse 
practitioners tend to overprescribe and overutilize diagnostic imaging 
and other services, contributing to higher health care costs. For 
example, a 2020 study published in the Journal of General Internal 
Medicine found 3.8 percent of physicians (MDs/DOs), compared to 8 
percent of nurse practitioners and 9.8 percent of physician assistants 
met at least one definition of overprescribing opioids and 1.3 percent 
of physicians compared to 8.4 percent of physician assistants and 6.3 
percent of nurse practitioners prescribed an opioid to at least 50 
percent of patients.\10\ The study further found that, in states that 
allow independent prescribing, nurse practitioners and physician 
assistants were 20 times more likely to overprescribe opioids than 
those in prescription-restricted states.\11\
---------------------------------------------------------------------------
    \10\ MJ Lozada, MA Raji, JS Goodwin, YF Kuo, ``Opioid Prescribing 
by Primary Care Providers: A Cross-Sectional Analysis of Nurse 
Practitioner, Physician Assistant, and Physician Prescribing 
Patterns.'' Journal General Internal Medicine. 2020; 35(9):2584-2592.
    \11\ Id.
---------------------------------------------------------------------------
    Multiple studies have also found that physician assistants and 
nurse practitioners tend to prescribe unnecessary antibiotics.\12\ A 
study in Infection Control & Hospital Epidemiology which examined 
prescribing data for patients with common upper respiratory infection 
that should not require antibiotics and found that adults seen by nurse 
practitioners or physician assistants were 15 percent more likely to 
receive an antibiotic compared to those patients seen by a physician. 
Similar rates were found for pediatric patients.\13\ Unnecessary 
antibiotic prescribing leads to antibiotic resistance which can have 
negative impact on a patient's future ability to fight infection.
---------------------------------------------------------------------------
    \12\ Sanchez GV, Hersh AL, Shapiro DJ, et al. Brief Report: 
Outpatient Antibiotic Prescribing Among United States Nurse 
Practitioners and Physician Assistants. Open Forum Infectious Diseases. 
2016:1-4. Grijalva CG, Nuorti JP, Griffin MR. Antibiotic prescription 
rates for acute respiratory tract infections in US ambulatory settings. 
JAMA 2009; 302:758-66.
    \13\ Schmidt ML, Spencer MD, Davidson LE. Patient, Provider, and 
Practice Characteristics Associated with Inappropriate Antimicrobial 
Prescribing in Ambulatory Practices. Infection Control & Hospital 
Epidemiology. 2018:1-9.
---------------------------------------------------------------------------
    Multiple studies have also shown that physician assistants and 
nurse practitioners order more diagnostic imaging than physicians, 
which increases health care costs and threatens patient safety by 
exposing patients to unnecessary radiation. For example, a study in the 
Journal of the American College of Radiology, which analyzed skeletal 
X-ray utilization for Medicare beneficiaries from 2003 to 2015, found 
ordering increased substantially--more than 400 percent--by non-
physicians, primarily nurse practitioners and physician assistants, 
during this timeframe.\14\ A separate study published in JAMA Internal 
Medicine found that physician assistants and nurse practitioners 
ordered more diagnostic imaging than primary care physicians following 
an outpatient visit. The study controlled for imaging claims that 
occurred after a referral to a specialist.\15\ The authors opined this 
increased utilization may have important ramifications on costs, 
safety, and quality of care. They further found greater coordination in 
health care teams may produce better outcomes than merely expanding 
physician assistant or nurse practitioner scope of practice.
---------------------------------------------------------------------------
    \14\ D.J. Mizrahi, et.al. ``National Trends in the Utilization of 
Skeletal Radiography,'' Journal of the American College of Radiology 
2018; 1408-1414.
    \15\ D.R. Hughes, et al., A Comparison of Diagnostic Imaging 
Ordering Patterns Between Advanced Practice Clinicians and Primary Care 
Physicians Following Office-Based Evaluation and Management Visits. 
JAMA Internal Med. 2014;175(1):101-07.
---------------------------------------------------------------------------
    The findings are clear: nurse practitioners and physician 
assistants tend to prescribe more opioids than physicians, order more 
diagnostic imaging than physicians, and overprescribe antibiotics 
\16\--all which increase health care costs and threaten patient safety.
---------------------------------------------------------------------------
    \16\ Sanchez GV, Hersh AL, Shapiro DJ, et al. Brief Report: 
Outpatient Antibiotic Prescribing Among United States Nurse 
Practitioners and Physician Assistants. Open Forum Infectious Diseases. 
2016:1-4. Schmidt ML, Spencer MD, Davidson LE. Patient, Provider, and 
Practice Characteristics Associated with Inappropriate Antimicrobial 
Prescribing in Ambulatory Practices. Infection Control & Hospital 
Epidemiology. 2018:1-9.
---------------------------------------------------------------------------
    Finally, it is important to ensure that certified registered nurse 
anesthetists are properly overseen. There is no literature to support 
the safety of eliminating physician clinical oversight of anesthesia. 
To the contrary, independent literature points to the risk to patients 
of anesthesia without appropriate physician clinical oversight. For 
example, a study from Anesthesiology, found that patients having 
general or orthopedic surgery were eight percent more likely to die if 
anesthesia was not provided by a physician anesthesiologist.\17\ An 
additional study from the Journal of Clinical Anesthesia found that 
patients that had their anesthesia solely provided by a nurse 
anesthetist rather than a physician anesthesiologist were 80 percent 
more likely to have an unexpected disposition (admission to the 
hospital or death).\18\ Furthermore, a study from VA Evidence Synthesis 
Program Evidence Briefs, found that after the VA reviewed its own 
research resources, the VA's Quality Enhancement Research Initiative 
concluded that there was no evidence to support the safe implementation 
of nurse-only models of anesthesia for the VA especially for complex 
surgeries and in small or isolated VA hospitals.\19\ Last, multiple 
studies have found that when states choose to remove the Medicare 
physician supervision requirement for nurse anesthetists there is no 
evidence that access to care increases.\20\
---------------------------------------------------------------------------
    \17\ Silber JH, Kennedy SK, Even-Shoshan O, et al. Anesthesiologist 
direction and patient outcomes. Anesthesiology. 2000;93(1):152-163. 
doi:10.1097/00000542-200007000-00026.
    \18\ Memtsoudis SG, Ma Y, Swamidoss CP, Edwards AM, Mazumdar M, 
Liguori GA. Factors influencing unexpected disposition after orthopedic 
ambulatory surgery. J Clin Anesth. 2012;24(2):89-95. doi:10.1016/
j.jclinane.2011.10.002.
    \19\ McCleery E, Christensen V, Peterson K, Humphrey L, Helfand M. 
Evidence Brief: The quality of care provided by advanced practice 
nurses. In: VA Evidence Synthesis Program Evidence Briefs. Washington 
(DC): Department of Veterans Affairs (US); September 2014.
    \20\ Schneider JE, Ohsfeldt R, Li P, Miller TR, Scheibling C. 
Assessing the impact of state ``opt-out'' policy on access to and costs 
of surgeries and other procedures requiring anesthesia services. Health 
Econ Rev. 2017;7(1):10. doi:10.1186/s13561-017-0146-6; see also, Sun 
EC, Dexter F, Miller TR, Baker LC. ``Opt out'' and access to anesthesia 
care for elective and urgent surgeries among U.S. Medicare 
beneficiaries. Anesthesiology. 2017;126(3):461-471. doi:10.1097/
ALN.0000000000001504; Sun E, Dexter F, Miller TR. The effect of ``opt-
out'' regulation on access to surgical care for urgent cases in the 
United States: evidence from the National Inpatient Sample. Anesth 
Analg. 2016;122(6):1983-1991. doi:10.1213/ANE.0000000000001154.
---------------------------------------------------------------------------
    Nurse practitioners, nurse anesthetists, and physician assistants 
are integral members of the care team, but the skills and acumen 
obtained by physicians throughout their extensive education and 
training make them uniquely qualified to oversee and supervise 
patients' care. Physician-led team-based care has a proven track record 
of success in improving the quality of patient care, reducing costs, 
and allowing all health care professionals to spend more time with 
their patients. We urge Congress to invest in the proven track record 
of physician-led team-based care.

Patients Want Physicians: Patients have consistently stated that they 
want a physician as the head of their care team.

    In developing National Standards of Practice, patient sentiment 
should be considered and support for physician-led teams should be 
enhanced. Based on a series of nationwide surveys, patients 
overwhelmingly want physicians to lead their health care team. Four out 
of five patients want a physician leading their health care team and 95 
percent believe it is important for physicians to be involved in their 
medical diagnoses and treatment decisions (68 percent said it is very 
important). Moreover, only 3 percent of U.S. voters said it was not 
important to have physicians involved in specific treatments such as 
anesthesia, surgery, and other invasive procedures.\21\ Patients 
understand the value that physicians bring to the health care team and 
expect to have access to a physician to ensure that their care is of 
the highest quality. As such, developing National Standards of Practice 
that will potentially remove physicians from many veterans' health care 
teams goes against what patients want, which will decrease the quality 
of care received, patient confidence, and the effectiveness of the VHA.
---------------------------------------------------------------------------
    \21\ https://www.ama-assn.org/system/files/ama-scope-of-practice-
stand-alone-polling-toplines.pdf. The survey was conducted among 1,000 
U.S. voters between January 27th and February 1st, 2021. The margin of 
error is +/-3.5 at the 95 percent confidence interval.

State Based Licensure: The Federal Supremacy Project undermines state 
licensing boards and will further encourage inadequate oversight of 
---------------------------------------------------------------------------
non-physician practitioners within the VA.

    State licensing boards play an important role in ensuring that 
medical care is properly administered and that providers are 
disciplined when malpractice is committed. Such laws are often the 
result of extensive debate by state legislatures, sometimes spanning 
several years and involving negotiations among all stakeholders. 
However, the VA's decision to circumvent state scope of practice laws 
and regulations through the Federal Supremacy Project will make it 
impossible for state boards to oversee physicians and non-physician 
practitioners employed by the VA, leading to unintended 
consequences.\22\
---------------------------------------------------------------------------
    \22\ The vast majority of states support physician-led teams. For 
example, 38 states plus DC require physician supervision of physician 
assistants (PAs) and 11 states require PAs to practice pursuant to a 
collaboration agreement with a physician. Similarly, 20 states require 
physician involvement for nurse practitioners to diagnose, treat or 
prescribe and 14 more states require physician involvement for a 
certain number of hours or years of practice.
---------------------------------------------------------------------------
    Unlike physicians who are supposed to have their licenses reviewed 
every two years by the VA, registered nurses and other non-physician 
practitioners within the VA are appointed for an indefinite time, 
meaning that their credentials are reviewed before they are hired and 
may never be reviewed again.\23\ As a result, according to multiple 
Government Accountability Office (GAO) audits, the VA is doing an 
inadequate job of supervising and disciplining its non-physician 
practitioners. Over the past few years, the VA Office of Inspector 
General has reported multiple cases of quality and safety concerns 
regarding VA providers.\24\ The issues reported range from providers 
lacking appropriate qualifications, to poor performance and provider 
misconduct.\25\ Unfortunately, the VA has been deficient in putting an 
end to this subpar care in part, due to the fact that VA medical center 
officials lack the information they need to make decisions about 
providers' privileges due to poor VA reporting. Owing to the VA's 
inadequate oversight, VA medical center officials are not reviewing all 
of the providers for whom clinical care concerns were raised, and the 
VA is not taking appropriate adverse privileging actions.\26\ This 
includes certain VA medical centers not reporting providers to the 
National Practitioner Data Bank (NPDB) or to state licensing boards as 
is required by law.\27\ If the National Standards of Practice are 
implemented the oversight that these non-physician practitioners have 
will be lowered even more, leading to an increased lack of 
accountability for Veteran's care. Moreover, it will make it extremely 
difficult for state boards to oversee the practitioners that they 
license and will make it all but impossible to discipline VA-employed 
non-physician practitioners who inadequately care for Veterans. This 
lack of oversight means that patients' safety could easily be 
jeopardized, especially if the national standard for a particular 
provider-type differs from a state's scope of practice and licensing 
requirements. In these cases, it would be unclear whether the VA 
provider would have the necessary training, as dictated by the state 
licensing or medical board, to appropriately treat a patient and could 
potentially lead to Veterans receiving subpar care with little to no 
repercussions for the provider.
---------------------------------------------------------------------------
    \23\ https://www.gao.gov/assets/700/697173.pdf.
    \24\ https://www.gao.gov/assets/710/702090.pdf.
    \25\ Id.
    \26\ Id.
    \27\ Id.
---------------------------------------------------------------------------
    Since the VA already has numerous problems with quality of care, 
the VA should not expand its scope of practice parameters and allow 
non-physician practitioners to perform procedures for which they are 
not properly licensed or trained. By implementing the Federal Supremacy 
Project, the VA is making it difficult for state boards to oversee the 
practitioners that they license and will likely make it tougher to 
discipline non-physician practitioners who inadequately care for 
patients due to a lack of clarity about these practitioners' scope of 
practice. Since it has been shown that the VA is unable to adequately 
oversee health care providers, it is vital to rescind or restructure 
the Federal Supremacy Project and ensure that state licensing boards 
can adequately supervise their non-physician practitioners to ensure 
the highest quality of care for veterans.\28\
---------------------------------------------------------------------------
    \28\ https://www.gao.gov/assets/700/697173.pdf.
---------------------------------------------------------------------------
    We also believe that the IFR did not meet the standards set out in 
Executive Order 13132 and, by extension, is in violation of the 
Administrative Procedure Act (APA). The IFR preempts state law by 
asserting that state and local scope of practice laws relating to NPPs 
that are employed by the VA ``will have no force or effect,'' and that 
state and local governments ``have no legal authority to enforce 
them.'' However, the requirements to preempt state law, set forth in 
Executive Order 13132, have not been met.\29\ The VA did not ``provide 
all affected state and local officials notice and an opportunity for 
appropriate participation in the proceedings.'' \30\ This can be seen 
by the fact that the VA did not provide any time for comments and 
instead published the IFR on the same day the rule took effect, which 
gave no opportunity for any stakeholders to meaningfully participate in 
the proceedings.\31\ As such, the VA did not follow the guidelines set 
out in Executive Order 13132 and ``act only with the greatest 
caution,'' nor did the VA possess good cause when it bypassed the APA 
and acted arbitrarily and capriciously by failing to adequately 
consider the rights of the states and the long-term safety of our 
nations' Veterans.
---------------------------------------------------------------------------
    \29\ https://www.govinfo.gov/content/pkg/FR-1999-08-10/pdf/99-
20729.pdf.
    \30\ Id.
    \31\ Id.

Electronic Health Record (EHR): The VA should not be granted uniform 
---------------------------------------------------------------------------
practitioner privileging as a result of their inadequate EHR system.

    In the Interim Final Rule, the VA argued that non-physician 
practitioners need to practice independently due to the newly created 
EHR which purportedly requires uniform privileging irrespective of 
where care is delivered.\32\ ``An electronic health record (EHR) is a 
digital version of a patient's paper chart. EHRs are real-time, 
patient-centered records that make information available instantly and 
securely to authorized users.'' \33\ EHRs also provide privileging 
options, meaning that they will provide only a certain amount of access 
and authority to providers depending on their licensure. Despite 
multiple EHR systems across the U.S. allowing for differing levels of 
privileging, the VA argued that it must develop uniform standards of 
practice because the new EHR system, which it developed in conjunction 
with the Department of Defense over the course of years, requires all 
practitioners with the same license to have the same practice 
privileges. However, the VA recently announced that it will 
indefinitely delay the implementation of its EHR system due to multiple 
problems, including increased cost, and significant issues which have 
led to the death of multiple veterans.\34\, \35\ With this 
rationale removed from consideration, the VA should not be rewarded 
with a universalized privileging system for building a $10 billion EHR 
system that is subpar, defunct, and does not meet state scope of 
practice laws.\36\ Moreover, if there must be uniform privileging in 
the VA, then instead of setting practice privileges to align with the 
least restrictive scope provisions, the VA should ensure that veterans 
are provided with the best care and adhere to the most conservative 
State scope requirements.
---------------------------------------------------------------------------
    \32\ https://www.federalregister.gov/documents/2020/11/12/2020-
24817/authority-of-va-professionals-to-practice-health-care#p-65.
    \33\ https://www.healthit.gov/faq/what-electronic-health-record-
ehr.
    \34\ https://digital.va.gov/ehr-modernization/resources/ehr-
deployment-schedule/; https://subscriber.politicopro.com/article/2023/
04/vas-new-health-records-system-contributed-to-4-deaths-
00090830?source=email.
    \35\ https://digital.va.gov/ehr-modernization/resources/ehr-
deployment-schedule/.
    \36\ https://www.gao.gov/assets/710/700478.pdf.

---------------------------------------------------------------------------
Alternate Solutions to VA Health Care Needs

    The AMA understands the importance and need to have an adequately 
staffed health care facility. As such, we suggest that, instead of 
implementing the Federal Supremacy Project, additional funding is 
provided to the VHA to hire and train more physicians. Simultaneously, 
the VHA needs to accurately count all physicians providing care within 
its facilities, including trainees, to accurately understand where 
shortages exist and appropriately adjust hiring accordingly. The GAO 
has consistently found that the VHA is unable to accurately count the 
total number of physicians who provide care in its VA medical centers 
(VAMC) and the VA has disagreed with the recommendation of the GAO to 
develop and implement a process to accurately count all physicians 
providing care at each medical center.\37\, \38\
---------------------------------------------------------------------------
    \37\ https://www.gao.gov/products/gao-18-124#summary_recommend.
    \38\ https://www.gao.gov/assets/gao-22-105630.pdf.
---------------------------------------------------------------------------
    The VA is the largest provider of health care training in the 
United States. ``In general, each year approximately 43,000 individual 
physician residents receive their clinical training by rotating through 
about 11,000 VA-funded physician FTE residency positions at VA medical 
facilities.'' \39\ However, approximately 99 percent of the VA's 
programs are sponsored by outside medical schools or teaching 
hospitals. Functionally, this limits the amount of expansion that can 
occur in the VA system as those who train at VA locations must still be 
housed under a third-party graduate medical education (GME) program 
with full accreditation and administrative functioning. Therefore, the 
VA should work to create more of its own GME residency positions as 
well as continue to work with medical schools to expand existing 
partnerships and shared training slots. A few of the ways this could be 
accomplished include expanding the VA Pilot Program on Graduate Medical 
Education and Residency \40\ and expanding the number of positions 
available via the VA MISSION Act of 2018 \41\ and the Veterans Access, 
Choice and Accountability Act.\42\ Expansions could be made through the 
Department of Veterans Affairs Office of Academic Affiliations to help 
preserve and expand GME within the VHA. The expansion of GME within the 
VHA has already proven to be successful in retaining physicians. For 
example, the annual Trainee Satisfaction Survey administered by the VA 
Office of Academic Affiliations to physician residents consistently 
finds that residents have a more positive opinion regarding a career at 
the VA after completing their rotations, with over half (55 percent) 
responding they would consider a career at a VA medical center.\43\ If 
the full funding for the direct and indirect costs of GME positions was 
expanded within the VA more physicians would be able to work within the 
VA, which would decrease existing shortages while providing high 
quality care for veterans.
---------------------------------------------------------------------------
    \39\ https://sgp.fas.org/crs/misc/R44376.pdf.
    \40\ https://www.federalregister.gov/documents/2022/02/04/2022-
02292/va-pilot-program-on-graduate-medical-education-and-residency.
    \41\ https://www.govinfo.gov/content/pkg/COMPS-15905/pdf/COMPS-
15905.pdf.
    \42\ https://www.govinfo.gov/content/pkg/COMPS-15905/pdf/COMPS-
15905.pdf.
    \43\ https://journals.lww.com/academicmedicine/Fulltext/2022/08000/
Veterans_Affairs_Graduate_Medical_Eduction.37.aspx.
---------------------------------------------------------------------------
    For the first time in years the staffing shortages within the VHA 
have intensified, resulting in a 22 percent increase in occupational 
staffing shortages in 2022 compared to 2021.\44\ Some of the 
professions with the severest shortages within the VHA include 
psychiatrists, primary care physicians, and gastroenterologists.\45\ As 
such, another potential solution to the physician shortage is to hire 
more physicians and provide additional benefits to physicians working 
within the VA to help with retention.
---------------------------------------------------------------------------
    \44\ https://www.va.gov/oig/pubs/VAOIG-22-00722-187.pdf.
    \45\ https://www.va.gov/oig/pubs/VAOIG-22-00722-187.pdf.
---------------------------------------------------------------------------
    Within the VHA, physician salaries are determined according to a 
combination of base pay, market pay, and performance pay. Moreover, 
under 38 U.S.C. 7431(e)(1)(A),\46\ every two years the Secretary must 
prescribe for Department-wide applicability the minimum and maximum 
amounts of VHA physicians annual pay.\47\ Therefore, under this statue, 
it would be possible to increase the pay offered to physicians within 
the VHA which would help with recruitment and retention. Furthermore, 
the VA should enhance its loan forgiveness and scholarship efforts to 
further incentivize physician recruiting and retention and improve 
patient access in the Veterans Administration facilities.
---------------------------------------------------------------------------
    \46\ https://www.govinfo.gov/content/pkg/USCODE-2018-title38/html/
USCODE-2018-title38-partV-chap74-subchapIII-sec7431.htm.
    \47\ https://www.federalregister.gov/documents/2019/12/09/2019-
26435/annual-pay-ranges-for-physicians-dentists-and-podiatrists-of-the-
veterans-health-administration-vha.
---------------------------------------------------------------------------
    Additionally, ensuring that all physician specialties are direct 
hires and streamlining the hiring process in general will help with the 
efficient and timely staffing of physicians. The hiring process for 
international medical graduates (IMG) should also be streamlined, 
including providing/expanding the exception to the two-year home 
country return requirement if an IMG works for the VHA for a designated 
period of time. The VA states for all its jobs that the hiring process 
``may take a while.'' In line with this, 94 percent of respondents to a 
survey about VA hiring stated that they had lost an interested 
candidate due to delays in the HR hiring process.\48\ As such, changes 
need to be made to the hiring and onboarding process so that good 
candidates are not lost to other jobs.
---------------------------------------------------------------------------
    \48\ https://www.afge.org/globalassets/documents/generalreports/
2023/03/vhpireport_v2.pdf.
---------------------------------------------------------------------------
    Finally, increasing access to the Community Care program when 
physician employment gaps cannot be filled will help to ensure that 
veterans continue to receive the care they need and increase access to 
physician services. However, the implementation of this program must be 
improved, including resolving delays in payment to participating 
providers. For example, a 225-bed health care system in South Carolina 
had $22.7 million in outstanding VA claims at the beginning of FY 2022 
with $16.7M (83 percent) over 90 days due. On top of this, the health 
care system had to write off approximately $12.7M during FY 22 because 
the VA claims were over 300 days old. As such, increasing reliability 
of payment for services rendered as part of the Community Care program 
and increasing the number of physicians and other health care 
professionals who are part of the program could help to fill workforce 
gaps.
    In line with this, the VHA should pay private physicians a minimum 
of 100 percent of Medicare rates for visits and approved procedures to 
ensure adequate access to care and choice of physician and ensure that 
clean claims submitted electronically to the VA are paid within 14 days 
and that clean paper claims are paid within 30 days. This would 
increase the willingness and variety of providers who would care for 
our veterans.

Conclusion

    Our nation's veterans should be provided with physician-led health 
care teams that consider important scope of practice limitations and 
make the most of the respective education and training of physicians 
and non-physician practitioners. Therefore, we oppose the 
implementation of the VA Federal Supremacy Project. Instead, additional 
investments in physicians and physician-led team-based care should be 
made to ensure that veterans receive the care they deserve. At the very 
least, we urge Congress to ensure that physician-led team-based care is 
maintained and that physician representation on all the Work Groups, 
not just the Physician Work Group, be mandatory.
                                 ______
                                 

                   Prepared Statement of Paul Barney
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

                   Prepared Statement of Janet Setnor
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

                  Prepared Statement of Stephen McLeod
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

                    Prepared Statement of Ron Harter
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

                  Prepared Statement of Erica Scavella

    Good morning, Chairman Miller-Meeks, Ranking Member Brownley and 
distinguished Members of the Subcommittee. Thank you for the 
opportunity today to discuss VHA's position regarding the National 
Standards of Practice (NSP). Accompanying me today is M. Christopher 
Saslo, DNS, APRN-BC, FAANP, Assistant Under Secretary for Health 
Patient Care Services/Chief Nursing Officer, and Mr. Ethan Kalett, 
Executive Director, Office of Regulations, Appeals and Policy.
    VA remains committed to honoring the Nation's Veterans by ensuring 
a safe environment to deliver exceptional health care. On November 12, 
2020, VA published an interim final rule confirming that VA health care 
professionals may practice their health care profession consistent with 
the scope and requirements of their VA employment, notwithstanding any 
State license, registration, certification, or other requirements that 
unduly interfere with their practice (38 CFR 17.419; 85 FR 71838). The 
rulemaking confirmed VA's authority to establish national standards of 
practice for its health care professionals in all VA medical facilities 
and explained that a national standard of practice describes the tasks 
and duties that a VA health care professional may perform and may be 
permitted to undertake regardless of the state in which the VA medical 
facility where they are located or the State license, registration, 
certification, or other State requirement they hold.
    VA continues to pursue national standards of practice for 51 
occupations (including nursing, dentistry, pharmacy, rehabilitation, 
diagnostics, social work, mental health) to ensure safe, high-quality 
care for the Nation's Veterans and to ensure that VA health care 
professionals can meet the needs of Veterans wherever they are located. 
National standards are designed to increase Veterans' access to health 
care and improve health outcomes.
    As the Nation's largest integrated health care system, VA must 
develop national standards of practice that ensure Veterans receive the 
same high-quality care regardless of where they enter the system. The 
importance of this initiative has been underscored by the COVID-19 
pandemic. The increased need for mobility in our workforce, including 
through VA's Disaster Emergency Medical Personnel System, exemplifies 
the necessity of uniform standards of practice in support of those VA 
health care professionals who practice across State lines. Furthermore, 
standardizing practice among VA health care occupations to decrease the 
variances in care by State requirements also creates improved access 
with VA. The lack of VA national standards can negatively impact the 
ability of Veterans across all states to have equal access to certain 
services.
    For example, some states, such as Missouri, require a provider's 
prior referral for Physical Therapy services. Direct access to these 
services, that is a provider referral is not necessary, is beneficial 
for increased access to health care, as it decreases wait times to 
receive care and decreases the burden on the referring provider, thus 
allowing the referring provider to see more Veteran patients. A VA 
Physical Therapist NSP could permit all physical therapy services to be 
initiated without a referral. By removing the additional step of 
requiring Veterans to first obtain a referral, VA can increase timely 
access to such services.
    A second example involves nursing and the ability to independently 
follow a protocol. A protocol is a standing order that has been 
approved by medical and clinical leadership if a certain sequence of 
health care events occur. For instance, if a patient is exhibiting 
certain signs of a heart attack, there is a protocol in place to 
administer potentially life-saving medication. If the nurse is the 
first person to see the signs, the nurse will follow the approved 
protocol and immediately administer the medication. However, if the 
State license does not permit a nurse to follow the protocol and 
requires a provider co-signature, administration of the medication will 
be delayed until a provider is able to co-sign the order, which may 
lead to the deterioration of the patient's condition. Co-signing 
protocols also increase the provider's workload and decrease the amount 
of time the provider can spend with patients. Almost all states permit 
nurses to follow a protocol; however, Texas does not permit nurses to 
follow a protocol without a provider co-signature. Thus, in Texas, 
timely delivery of life saving care could be delayed for veterans as 
compared to other states. The national standards of practice for 
nursing could permit all VA nurses to follow protocol without provider 
co-signature.
    VA is committed to ensuring that stakeholders are engaged in the 
process to develop national standards of practice for each and every 
health care occupation. The national standards of practice are being 
designed through extensive internal and external expert consultation 
with a focus on increasing Veterans' access to health care and ensuring 
health outcomes. There is an already established process for subject-
matter expertise inclusion, to include partnering with the Department 
of Defense to align national standards, when appropriate, which will 
apply to the development of all practice standards.
    To further engage with key stakeholders, VA hosted five listening 
sessions in August and September 2023, for professional associations, 
Veteran Service Organizations, the clinical community, the public, and 
Members of Congress to provide to VA their research, input and comments 
on variance between state licenses and scopes of practices, and their 
recommendations on what should be included in VA's national standards 
of practice. VA will consider all feedback received at these listening 
sessions when drafting the national standard of practice. In addition, 
the draft national standard (once ready) will be published in the 
Federal Register for public comment; and VA will send every State Board 
for that profession a letter with information on the impact of the 
proposed national standard of practice on the specific State, with an 
opportunity for the State Board to respond.
    VA remains committed to providing consistently high-quality patient 
care by qualified health care providers. The development of national 
standards of practice will not undo the longstanding team-based model 
of care already established within VA that ensures competent, safe and 
appropriate care for Veterans. When developing the national standards 
of practice, VA encourages a team-based approach to patient care and 
national standards of practice will support defined roles within the 
team regardless of State requirements or restrictions. National 
standards of practice are intended to strengthen team-based care by 
creating consistent standards nationwide, thereby generating the best 
possible access and outcomes for Veterans. However, privileges, scopes 
of practice and functional statements will continue to be specific to 
individuals based upon their education, training, experience, skill and 
clinical assignment.
    In regard to the certified registered nurse anesthetist (CRNA) 
national standard of practice, VA will only include independent 
practice if VA determines that it is appropriate, safe, and in the best 
interest of Veterans. Work on the CRNA NSPs is currently underway. As 
delineated in VHA Directive 1123, National Anesthesia Service, VA 
anesthesiologists and CRNAs will continue to provide team-based care, 
either under a scope of practice or privileges, where appropriate, to 
provide vital anesthesia care to Veterans throughout the United States.
    Currently, VHA Directive 1123, National Anesthesia Service, already 
includes language for VA CRNAs to practice independently if permitted 
by the facility bylaws and privileges, and if the CRNA is licensed in a 
state whose licensing boards have authorized independent practice for 
CRNAs. There is no evidence from impartial, independent studies, to 
indicate that full practice authority for CRNAs leads to either 
improved or adverse outcomes. Internally, VA monitors patient safety 
and quality of care through the Focused Professional Practice 
Evaluation (FPPE) and Ongoing Professional Practice Evaluation (OPPE) 
processes. These evaluations are standards required by The Joint 
Commission. To date, there have been no concerning FPPE/OPPE reports to 
indicate concerns regarding the safety and quality of independent 
practice authority either.
    VA continues to invest in the team-based model of care, and there 
is no planned change accompanying these National Standards of Practice 
development. As noted above, all the team models defined in VHA 1123 
are currently employed within the enterprise and already tested. Any 
local decision to change models of care delivery would be initiated by 
a need to improve access to care as well as subject to the very same 
quality standards and reviews already present in VA.
    VA engaged the Temple University School of Law to conduct an 
independent third-party comprehensive review of each State's practice 
acts for CRNAs and analyze the variance in CRNA practice across states 
. This data is now being used to develop the CRNA national standard of 
practice by a team of subject matter experts from within the anesthesia 
service, comprised of anesthesiologists, CRNAs, and other advanced 
practice nurses. The national standards of practice will be designed 
through extensive internal and external expert consultation with a 
focus on increasing Veterans' access to health care and improving 
health outcomes. There is an already established process for subject-
matter expertise inclusion, which will apply to the development of 
these practice standards.
    In regard to the optometry national standard of practice, VA is 
currently considering whether the national standard of practice will 
authorize optometrists in the 10 States that allow laser eye surgery 
(AK, AR, CO, IN, KY, LA, MS, OK, VA, WY) to practice and operate within 
the full scope of their license in VA facilities. VA does not intend to 
allow VA optometrists who hold a license in any other State to perform 
laser eye surgery, this authority would only be considered for the 
states that already authorize them to perform laser eye surgery. VA 
held a listening session on August 31, 2023, and allowed stakeholders 
invested in VA eye care the opportunity to provide research, input, 
comments, and recommendations on what they believe should be included 
in VA's proposed optometrist national standard of practice. Thirteen 
organizations presented to VA, including numerous professional 
societies and VSOs. VA is using the information presented by external 
stakeholders to determine what should be included in the proposed 
national standard of practice that will be published in the Federal 
Register for public comment in the future. The forthcoming proposed 
national standards of practice will ensure that VA upholds safe, high-
quality care for the Nation's Veterans and ensure VA optometrists can 
meet the needs of Veterans when practicing within the scope of their VA 
employment.
    VHA is sensitive to issues regarding the safety of Veterans in our 
care. As a High Reliability Organization (HRO), VA continuously 
monitors the quality and safety of care delivered to Veterans and works 
to ensure excellence for each Veteran in our care. HROs are 
organizations that achieve safety, quality and efficiency goals by 
employing five central principles, including sensitivity to operations; 
reluctance to simplify; preoccupation with failure; deference to 
expertise and practicing resilience. VA strives to continuously meet 
these goals, always holding ourselves and our organization to the 
highest possible standard. Since the standards of practice are still in 
the developmental stages and no changes to the model of care have been 
made, we will continue to monitor for issues and respond should they 
arise.

Conclusion

    We are committed to excellence in clinical care, utilizing our 
highly skilled workforce in a manner commensurate with their training 
and expertise. We appreciate the input of Congress and our other 
stakeholders in ensuring this commitment is always met. We especially 
appreciate the Committee's efforts in helping VA continue to deliver 
safe, high-quality care to Veterans.
    Chairwoman Miller-Meeks and Ranking Member Brownley, we appreciate 
your continued support and look forward to answering your questions.

                       Statements for the Record

                              ----------                              


               Prepared Statement of The American Legion
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

    Prepared Statement of National Conference of State Legislatures
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

           Prepared Statement of American Nurses Association

    The American Nurses Association (ANA) would like to thank the House 
Veterans' Affairs Subcommittee on Health for this opportunity to submit 
a statement for the record with respect to the subcommittee's oversight 
hearing on ``VA's Federal Supremacy Initiative: Putting Veterans 
First?'' As the voice of our nation's nurses, ANA is committed to 
working with the House Veterans' Affairs Committee and the U.S. 
Department of Veterans' Affairs (VA) to ensure that our nation's 
veterans and their families have access to highly qualified healthcare 
professionals during their time of need. With this mission in mind and 
given how nurses provide care for VA patients on a national basis, ANA 
supports the VA's ongoing efforts to develop national practice 
standards for nurses and other providers. This initiative gives nurses 
needed flexibility to practice across state lines, improving VA 
capacity to meet veterans' needs in more areas of the country.
    The VA has struggled for years to recruit and retain nurses and 
other healthcare professionals, which has in turn adversely impacted 
veterans' access to timely, high-quality care. This predicament has 
gotten worse since the COVID-19 pandemic. According to a report 
published last year by the VA' Office of Inspector General, 91 percent 
of VA facilities reported severe shortages for nurses during Fiscal 
Year 2022.\1\ As the VA works to address this nursing shortage crisis, 
it cannot afford to underutilize its existing nursing workforce.
---------------------------------------------------------------------------
    \1\ OIG Determination of Veterans Health Administration's 
Occupational Staffing Shortages Fiscal Year 2022 (va.gov)
---------------------------------------------------------------------------
    Registered Nurses (RNs) have a critical role in the care of 
patients within the VA. RNs are frequently the provider who has the 
most contact with patients, and therefore offer unique insights into 
the needs of their patients. Unfortunately, nurse burnout is worsening 
the shortage of nurses nationwide. ANA's most recent survey shows that 
almost half of nurses are considering leaving their current position 
and a lower, but not insignificant, percent are considering changing 
professions and leaving nursing entirely.\2\ This would allow RNs to 
practice at the top of their license and would provide flexibility to 
the VA by allowing nurses to practice where they are most needed within 
the VA system.
---------------------------------------------------------------------------
    \2\ https://www.nursingworld.org/practice-policy/work-environment/
health-safety/disaster--preparedness/coronavirus/what-you-need-to-know/
annual-survey--third-year
---------------------------------------------------------------------------
    Certified Registered Nurse Anesthetists (CRNAs) play a vital role 
in providing anesthesia care across the care continuum, ranging from 
general anesthesia to regional anesthesia to non-opioid pain 
management. Past studies have shown that CRNAs can render high-quality 
anesthesia care without physician supervision.\3\ In fact, CRNAs in 
other federal health systems and the armed services have been granted 
full practice authority. This is why it is crucial for the VA to 
promptly develop and issue national standards that empower Certified 
Registered Nurse Anesthetists (CRNAs) employed within the VA healthcare 
system to practice to the full extent of their education and licensure.
---------------------------------------------------------------------------
    \3\ https://www.healthaffairs.org/doi/full/10.1377/
hlthaff.2008.0966
---------------------------------------------------------------------------
    In closing, ANA appreciates this opportunity to share the nursing 
community's perspective on how the VA can utilize the federal supremacy 
initiative to expand access to care for veterans and their families. We 
stand ready to work with this subcommittee and the full committee to 
advance this mission. Should you have any questions, please reach out 
to Tim Nanof, Vice President of Policy and Government Affairs, at (301) 
628-5081 or [email protected].
                                 ______
                                 

           Prepared Statement of Nursing Community Coalition
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

      Prepared Statement of American Academy of Family Physicians
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

          Prepared Statement of Jewish War Veterans of the USA
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

      Prepared Statement of American Society of Retina Specialists

    The American Society of Retina Specialists (ASRS) is the largest 
retina organization in the world, representing over 3,500 board-
certified ophthalmologists who have completed fellowship training in 
the medical and surgical treatment of retinal diseases. The mission of 
the ASRS is to provide a collegial open forum for education, to advance 
the understanding and treatment of vitreoretinal diseases, and to 
enhance the ability of its members to provide the highest quality of 
patient care.
    ASRS counts many veterans and physicians who have trained at 
Veterans Affairs (VA) hospitals as its members. We thank the committee 
for this hearing and appreciate the opportunity to share our deep 
concern about a potential, unprecedented scope of practice expansion 
for optometrists providing care in VA facilities.
    As the VA continues to develop standards of practice for numerous 
allied health professionals providing necessary care to veterans in VA 
facilities, we ask for Congress' oversight to ensure veterans' eye 
health is protected. We ask for your support to prevent the VA from 
proposing standards for optometrists that allow them to perform 
surgical or invasive procedures, which are currently well outside of 
the majority of state licensing restrictions and standard optometric 
training.

Significant Differences in Training

    Retina specialists, like other ophthalmologists, have completed 
four years of medical school, a hospital internship, and three years of 
ophthalmology residency training, and then completed an additional two-
year retina fellowship. During their education, retina specialists 
receive extensive one-on-one training in surgical techniques and 
managing potential complications--both ocular and systemic. 
Successfully operating on eyes requires meticulous and finely honed 
microsurgical techniques. While it is frequently performed with little 
or no complications, that success is directly attributable to the 
proficiency of retina specialists and other ophthalmologists. These 
delicate procedures carry the risk of irreversible vision loss if not 
performed at an expert level.
    Optometrists, by comparison, have no such training. The typical 
optometric education rarely goes beyond the post-graduate level and 
mainly focuses on examining the eye for vision prescriptions, 
dispensing corrective lenses, performing some eye screening functions, 
and prescribing topical medications. While optometrists are an integral 
part of the eyecare team, they are generally not permitted to perform 
invasive procedures on the general population, so expanding their scope 
through the VA poses risks to veterans they would not face if they 
sought care from private facilities.

Current Scope of Practice Issues

    We believe our fears that a proposed standard would vastly and 
inappropriately expand optometrists' scope of practice in the VA are 
not unfounded. In September 2022, the VA removed language from its 
Community Care ``Standardized Episode of Care: Eye Care Comprehensive'' 
guidelines stating ``only ophthalmologists can perform invasive 
procedures, including injections, lasers, and eye surgery.'' This 
change was made without input from the ophthalmic community and we 
believe presages what will be included in the proposed standards of 
practice--without congressional oversight.
    The effort to expand optometrists' scope of practice in the VA 
system mirrors similar attempts on the state level. In nearly every 
state, there have been attempts to modify state licensing requirements 
to allow optometrists to perform surgical procedures. Yet, they have 
only been successful in a handful of states. In 2022, California 
Governor Gavin Newsom vetoed an optometric surgery bill specifically 
citing the lack of training as the rationale behind his decision. We 
ask Congress to urge VA to approach this issue like so many states have 
to date and prevent potential harm to veterans' eye health.
    Most importantly, preventing the VA from expanding the scope of 
optometric practice will protect all patients, not just veterans. While 
state-based efforts have not been overall successful, a national 
standard that allows optometrists to perform surgery could 
inappropriately prompt further changes at the state level. Congress 
must step in to ensure the VA Supremacy Project does not have 
unintended consequences beyond the VA system.

Potential Negative Tradeoffs

    Empowering untrained optometrists to perform surgical procedures 
would be an unprecedented break with current standards of care. Since 
there is no standard for training optometrists to perform surgical 
procedures and very few states where it is permissible, allowing 
optometrists to perform procedures in the VA is essentially offering up 
our Nation's veterans as unwitting guinea pigs in a trial of untrained 
professionals' surgical skill.
    The argument for allowing optometrists to perform procedures is 
generally that it will expand access to eye care for veterans. While 
ASRS agrees that veterans deserve timely access to care, we do not 
believe that quality of care should be shortchanged to meet that goal. 
Veterans are a precious group of patients who have risked their lives 
for the safety and security of our Nation. We owe it to them to ensure 
they do not receive sub-standard care. If an identifiable access issue 
exists, we urge Congress to work with the VA to find other, more 
appropriate means of addressing it rather than lowering the quality of 
eye care for veterans.
    ASRS thanks the committee for holding this hearing to investigate 
this issue. We believe Congress shares our goal of providing the 
nation's veterans with the highest standard of care and hope it will 
join us in advocating against allowing optometrists to perform surgical 
and invasive procedures. We would be happy to provide you with any 
assistance or additional information you may need. Please contact 
Allison Madson, vice president of health policy, at 
[email protected] for assistance.
                                 ______
                                 

   Prepared Statement of American Association of Nurse Practitioners

    The American Association of Nurse Practitioners (AANP) appreciates 
the opportunity to submit a statement for the record to the House 
Veterans' Affairs Subcommittee on Health hearing entitled ``VA's 
Federal Supremacy Initiative: Putting Veterans First?'' AANP represents 
the more than 355,000 nurse practitioners (NPs) in the United States 
and is committed to empowering all NPs to advance high-quality, 
equitable care, while addressing health care disparities through 
practice, education, advocacy, research, and leadership (PEARL).\1\ For 
the record, we support our certified registered nurse anesthetist 
(CRNA) colleagues in their efforts to seek Full Practice Authority 
(FPA) in the Department of Veterans Affairs (VA) and encourage the VA 
to move forward with a process to implement this policy. As outlined 
below, the VA previously authorized NPs to practice to the full extent 
of their education and clinical training within VA facilities, and this 
decision has yielded positive results for our nation's veterans.
---------------------------------------------------------------------------
    \1\ https://www.aanp.org/advocacy/advocacy-resource/position-
statements/commitment-to-addressing-health-care-disparities-during-
covid-19
---------------------------------------------------------------------------
    NPs are advanced practice registered nurses (APRNs) who are 
prepared at the masters or doctoral level to provide primary, acute, 
chronic and specialty care to patients of all ages and backgrounds. 
Daily practice includes assessment; ordering, performing, supervising 
and interpreting diagnostic and laboratory tests; making diagnoses; 
initiating and managing treatment including prescribing medication and 
non-pharmacologic treatments; coordinating care; counseling; and 
educating patients and their families and communities. NPs currently 
provide a substantial portion of the high-quality \2\, cost-effective 
\3\ care that our communities require, including the over 5,000 NPs 
practicing within VHA facilities.\4\ NPs are also essential to 
addressing issues of health equity, as they provide a substantial 
portion of health care in rural areas and areas of lower socioeconomic 
and health status.\5\, \6\, \7\
---------------------------------------------------------------------------
    \2\ https://www.aanp.org/images/documents/publications/
qualityofpractice.pdf.
    \3\ https://www.aanp.org/images/documents/publications/
costeffectiveness.pdf.
    \4\ 81 Fed. Reg. 90198, 90200. (Based on VHA payroll data from 
August 31, 2016, the VHA employees 5,444 NPs).
    \5\  Davis, M. A., Anthopolos, R., Tootoo, J., Titler, M., Bynum, 
J. P. W., & Shipman, S. A. (2018). Supply of Healthcare Providers in 
Relation to County Socioeconomic and Health Status. Journal of General 
Internal Medicine, 4-6. https://doi.org/10.1007/s11606-017-4287-4
    \6\ Xue, Y., Smith, J. A., & Spetz, J. (2019). Primary Care Nurse 
Practitioners and Physicians in Low-Income and Rural Areas, 2010-2016. 
Journal of the American Medical Association, 321(1), 102-105. https://
jamanetwork.com/journals/jama/fullarticle/2720014
    \7\ Andrilla, C. H. A., Patterson, D. G., Moore, T. E., Coulthard, 
C., & Larson, E. H. (2018). Projected Contributions of Nurse 
Practitioners and Physicians Assistants to Buprenorphine Treatment 
Services for Opioid Use Disorder in Rural Areas. Medical Care Research 
and Review, Epub ahead. https://doi.org/10.1177/1077558718793070
---------------------------------------------------------------------------
    NPs practice in nearly every health care setting including VHA 
facilities, schools and school-based clinics, hospitals, Indian Health 
Services facilities, emergency rooms, urgent care sites, private 
physician or NP practices (both managed and owned by NPs), skilled 
nursing facilities (SNFs), nursing facilities (NFs), colleges and 
universities, retail clinics, public health departments, nurse managed 
clinics, homeless clinics, and home health. NPs hold prescriptive 
authority in all 50 states and the District of Columbia. Currently, 
twenty-seven states and D.C. are full practice authority (FPA) states 
because their licensure laws allow full and direct access to NPs.\8\ In 
the majority of states, NPs are authorized under FPA to practice to the 
full extent of their education and clinical training without a 
regulated relationship with a physician.
---------------------------------------------------------------------------
    \8\ https://www.aanp.org/advocacy/state/state-practice-environment.
---------------------------------------------------------------------------
    As you know, on December 14, 2016, the VA finalized rulemaking to 
authorize NPs to practice to the full extent of their education and 
clinical training within VA facilities. That final rule recognized the 
value of NPs in the VA system, and that implementing VA FPA would 
increase access to high-quality care for veterans.\9\ This approach is 
in line with the majority of states as well as the Indian Health 
Service. Many federal agencies, including the Federal Motor Carrier 
Safety Administration, Social Security Administration, United States 
Marshals Service, United States Coast Guard, the Public Health Services 
Corps, the Federal Employees Health Benefits Program, recognize the 
importance and quality of care provided by NPs. We have been pleased to 
see that the VA has implemented FPA for NPs across all VA facilities 
since the rule was published and that data demonstrates that FPA has 
had a positive impact on wait times in mental health, specialty care 
and primary care for our Nation's veterans.\10\
---------------------------------------------------------------------------
    \9\ 81 Fed. Reg. 90198 (December 14, 2016).
    \10\ https://department.va.gov/wp-content/uploads/2022/09/va-
strategic-plan-2022-2028.pdf (at page 33).
---------------------------------------------------------------------------
    These findings are consistent with research outside of the VA which 
has also shown that NPs are essential to ensuring patients have access 
to high-quality health care, particularly among rural and underserved 
populations. According to the Medicare Payment Advisory Commission 
(MedPAC), APRNs and PAs comprise approximately one-third of our primary 
care workforce, and up to half in rural areas.\11\ MedPAC also found 
that, among all clinician types, NPs on average had the highest share 
of allowed charges associated with low-income subsidy (LIS) 
beneficiaries, which includes Medicaid beneficiaries. ``In 2019, 41 
percent of the allowed charges billed by NPs who practiced in primary 
care were for LIS beneficiaries, as were 36 percent for NPs who 
practiced in specialty care compared with 28 percent for primary care 
physicians and PAs and 25 percent for specialty care physicians and 
PAs.'' \12\ A 2019 study of Medicaid participation of buprenorphine 
waivered providers in Virginia found that buprenorphine waivered NPs 
were more likely to treat Medicaid patients compared to physicians and 
the probability of an NP treating a large number of Medicaid patients 
was higher among NPs relative to physicians.\13\ A recent study 
published in Health Affairs also found that from 2011-2019 the number 
of psychiatric-mental health NPs (PMHNPs) treating Medicare 
beneficiaries grew by 162 percent, compared to a 6 percent drop in 
psychiatrists during that same period.\14\ The study also found that 
the proportion of all mental health prescriber visits provided by 
PMHNPs to Medicare beneficiaries increased from 12.5 percent to 29.8 
percent during that same period, exceeding 50 percent in rural, full 
practice authority regions.\15\
---------------------------------------------------------------------------
    \11\ https://www.medpac.gov/wp-content/uploads/2022/06/
Jun22_MedPAC_Report_to_Congress_SEC.pdf (see Chapter 2.)
    \12\ https://www.medpac.gov/wp-content/uploads/2023/03/
Mar23_MedPAC_Report_To_Congress_SEC.pdf (Page 135).
    \13\ Saunders, Heather, et.al (2022). Medicaid Participation Among 
Practitioners Authorized to Prescribe Buprenorphine. Journal of 
Substance Abuse Treatment, Epub. https://pubmed.ncbi.nlm.nih.gov/
34148758/.
    \14\ Cai, Arno, et.al (2022). Trends in Mental Health Care Delivery 
by Psychiatrists and Nurses Practitioners in Medicare, 2011-2019. 
Health Affairs, 41(9), 1222-1230. https://www.healthaffairs.org/doi/
full/10.1377/hlthaff.2022.00289
    \15\ Ibid.
---------------------------------------------------------------------------
    In 2010 the Institute of Medicine (IOM) issued The Future of 
Nursing: Leading Change, Advancing Health report, which called for the 
removal of laws, regulations, and policies that prevent APRNs from 
providing the full scope of health care services they are educated and 
trained to provide. This position was reaffirmed by the National 
Academy of Medicine (previously the IOM) in their 2021 The Future of 
Nursing 2020-2030: Charting a Path to Achieve Health Equity report.\16\ 
The World Health Organization's State of the World's Nursing 2020 
report also recommends modernizing regulations to authorize APRNs to 
practice to the full extent of their education and clinical training, 
noting the positive impact it would have on addressing health care 
disparities and health care access within vulnerable communities.\17\ 
The merits of the high-quality care provided by NPs have been widely 
praised by bipartisan stakeholders such as the American Enterprise 
Institute \18\ and the Brookings Institution \19\, as well as 
bipartisan recognition from multiple administrations.\20\, 
\21\ Additionally, the Federal Trade Commission has highlighted how 
barriers to practice on APRNs are unnecessary and limit 
competition.\22\ Decades of evidence demonstrates that NPs provide 
high-quality, cost--effective health care with high patient 
satisfaction both inside and outside of the VA, examples of studies 
include:
---------------------------------------------------------------------------
    \16\ The Future of Nursing 2020-2030 National Academies. (see Page 
363).
    \17\ https://apps.who.int/iris/bitstream/handle/10665/331673/
9789240003293-eng.pdf
    \18\ https://www.aei.org/research-products/report/nurse-
practitioners-a-solution-to-americas-primary-care-crisis/.
    \19\ https://www.brookings.edu/wp-content/uploads/2018/06/
AM_Web_20190122.pdf.
    \20\ https://www.govinfo.gov/content/pkg/FR-2019-10-08/pdf/2019-
22073.pdf (see Section 5).
    \21\ https://www.healthaffairs.org/do/10.1377/
forefront.20220404.728371/. (ACO REACH also includes a nurse 
practitioner services benefit enhancement designed to reduce barriers 
to care access, particularly for individuals with limited access to 
physicians. Through waivers, this strategy would authorize nurse 
practitioners to certify patient needs (for example, for hospice) and 
order and supervise certain services (for example, cardiac 
rehabilitation).
    \22\ https://www.ftc.gov/system/files/documents/reports/policy-
perspectives-competition-regulation-advanced-practice-nurses/
140307aprnpolicypaper.pdf.

      A recent study utilizing VA data from FY 2013 found 
significant savings, 6-7 percent lower costs, for highly complex 
diabetic patients who had an NP as their primary provider compared to 
those with a physician.\23\ Other researchers found even greater 
savings, 12-13 percent lower costs when examining diabetic patients 
with varying degrees of complexity served by the VA. For a single VAMC 
this equated to an annual savings of just over $14 million exemplifying 
the efficiency and effectiveness of NP delivered care in the VA.\24\
---------------------------------------------------------------------------
    \23\ Morgan, et.al (2019). Impact of Physicians, Nurse 
Practitioners, And Physician Assistants On Utilization and Costs for 
Complex Patients. Health Affairs, 38(6), 1028-1036. https://
www.healthaffairs.org/doi/10.1377/hlthaff.2019.00014.
    \24\ Rajan, et. al (2021) ``Health care costs associated with 
primary care physicians versus nurse practitioners and physician 
assistants''. https://pubmed.ncbi.nlm.nih.gov/34074952/.

      Results from 806,434 patients at 530 Veterans Health 
Administration (VA) facilities found that patients assigned to primary 
care nurse practitioners were less likely to utilize additional 
services, had no difference in costs and experienced similar chronic 
disease management compared to physician-assigned patients.\25\
---------------------------------------------------------------------------
    \25\ Liu, C. F., Hebert, P. L., Douglas, J. H., Neely, E. L., Sulc, 
C. A., Reddy, A., & Wong, E. S. (2020).Outcomes of primary care 
delivery by nurse practitioners: Utilization, cost, and quality of 
care. Health Services Research, 55(2), 178-189. https://
pubmed.ncbi.nlm.nih.gov/31943190/

      Meta-analysis of studies comparing the quality of primary 
care services of physicians and NPs demonstrates the role NPs play in 
reinventing how primary care is delivered. The authors found that 
comparable outcomes are obtained by both providers, with NPs performing 
better in terms of time spent consulting with the patient, patient 
follow ups and patient satisfaction.\26\
---------------------------------------------------------------------------
    \26\ Naylor, M.D. and Kurtzman, E.T. (2010). The Role of Nurse 
Practitioners in Reinventing Primary Care. Health Affairs, (5), 893-99. 
https://pubmed.ncbi.nlm.nih.gov/20439877/

      The outcomes of NP care were examined through a 
systematic review of 37 published studies, most of which compared NP 
outcomes with those of physicians. Outcomes included measures such as 
patient satisfaction; patient perceived health status; functional 
status; hospitalizations; emergency department visits; and biomarkers 
such as blood glucose, serum lipids and blood pressure. Newhouse, et 
al., conclude that NP patient outcomes are comparable to those of 
physicians.\27\
---------------------------------------------------------------------------
    \27\ Newhouse, R.P., Stanik-Hutt, J., White, K.M., Johantgen, M., 
Bass, E.B., Zangaro, G., Wilson, R.F., Fountain, L., Steinwachs, D.M., 
Heindel, L., & Weiner, J.P. (2011). Advanced practice nurse outcomes 
1999-2008: A systematic review. Nursing Economics, 29(5), 1-22. https:/
/pubmed.ncbi.nlm.nih.gov/22372080/

      A 2022 Morning Consult poll found that 82 percent of 
patients support authorizing NPs to practice to the full extent of 
their education and clinical training.\28\
---------------------------------------------------------------------------
    \28\ https://connectwithcare.org/wp-content/uploads/2022/04/
Telehealth_MC-Branded_PPT_Final.pdf.

    Last, we would also like to take this opportunity to directly 
address the misinformation that has been raised with respect to the NP 
profession and the care provided to patients. To be clear, contrary to 
the Statement for the Record submitted by the American Medical 
Association (AMA), the VA is not currently hosting a listening session 
on NPs and there is no open feedback period on NPs (the VA finalized NP 
Standards of Practice in 2016). Yet, the AMA still used their 
opportunity to provide feedback to the subcommittee to denigrate their 
NP colleagues. In doing so, the AMA referenced non-peer reviewed 
reports with small sample sizes (such as those from the Hattiesburg 
Clinic and the National Bureau of Economic Research) while ignoring the 
substantial body of well-conducted, independent research that has shown 
that NPs provide high-quality care comparable to their physician 
colleagues. Arbitrary barriers to practice, such as those promoted by 
the AMA, do not improve patient care and do not support patient access 
to treatment.
    For example, after Congress authorized NPs to prescribe 
buprenorphine for the treatment of opioid use disorder in the 
Comprehensive Addiction Recovery Act, states without restrictive 
practice environments for NPs saw a significantly larger increase in 
waived clinicians (particularly rural counties) than more restrictive 
states.\29\ This is just one example that demonstrates that policies 
that prevent clinicians from practicing to the full extent of their 
education and clinical training only harm patients. Additionally, the 
AMA references two Government Accountability Office (GAO) reports that 
they claim show that the VA is doing an inadequate job of supervising 
and disciplining non-physician practitioners. However, they do not 
mention that these reports also included discussion of oversight of 
physicians, who are actually the most common provider type in the 57 
case studies that were included. For reference, only two of the case 
studies included NPs (neither of which found wrongdoing by the NP), and 
25 case studies involved physicians with multiple individuals having 
their VA employment terminated due to their conduct. To infer that 
these reports were limited to non-physicians is not an accurate 
representation of the reports.
---------------------------------------------------------------------------
    \29\ Barnett, Michael L., Lee, Dennis, & Frank, Richard G. (2019). 
In Rural Areas, Buprenorphine Waiver Adoption Since 2017 Driven by 
Nurses Practitioners And Physician Assistants. Health Affairs, 38(12), 
2048-2056. https://www.healthaffairs.org/doi/full/10.1377/
hlthaff.2019.00859.
---------------------------------------------------------------------------
    In closing, AANP recognizes and appreciates the contributions of 
all members of the health care team to high-quality patient care, and 
it is essential that all health care professionals be authorized to 
work to the top of their education and clinical training to best serve 
our nation's veterans. This is consistent with the team-based care 
model endorsed by the National Academy of Medicine which focuses on 
constructing a team that is tailored to meet the specific needs of the 
patient.\30\ AANP is pleased to take this opportunity to highlight the 
success of the VA's decision in 2016 to authorize NPs in VHA facilities 
to practice to the full extent of their education and clinical 
training. AANP hopes the objectively positive results yielded for our 
veterans is instructive to the subcommittee. We look forward to working 
with the subcommittee on ways to continue to improve the health care of 
our nation's veterans. We thank the subcommittee for holding a hearing 
on this important topic.
---------------------------------------------------------------------------
    \30\ https://www.aanp.org/advocacy/advocacy-resource/position-
statements/team-based-care.
---------------------------------------------------------------------------
                                 ______
                                 

           Prepared Statement of Blinded Veterans Association
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

            Prepared Statement of Fleet Reserve Association
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

         Prepared Statement of American Pharmacists Association
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

         VA Document for the Record, Briefings and Engagements
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]


                                 [all]