[Congressional Record (Bound Edition), Volume 147 (2001), Part 5]
[Senate]
[Pages 6939-6940]
[From the U.S. Government Publishing Office, www.gpo.gov]



   COMMUNITY-BASED OUTPATIENT CLINICS IN THE DEPARTMENT OF VETERANS 
                                AFFAIRS

  Mr. ROCKEFELLER. Mr. President, Congress transformed the landscape of 
health care delivery for veterans with the Veterans' Health Care 
Eligibility Reform Act of 1996. This law eliminated barriers to 
outpatient care and encouraged the Department of Veterans Affairs, VA, 
to offer health care services to veterans in the most clinically 
appropriate setting. VA responded by shifting its emphasis from 
hospital-based treatment to outpatient care, and in just a few years 
has opened more than 250 new community-based outpatient clinics.
  I am enormously pleased that VA has opened community clinics in West 
Virginia and throughout the country. It is critical to bring health 
care services closer to veterans, especially as our veterans population 
continues to age. But it is not sufficient merely to increase the 
accessibility of care, we must also ensure that veterans receive the 
highest quality of care possible. Just as I fought to secure outpatient 
clinics for veterans, I will fight to ensure that these clinics are the 
very best that they can be.
  At my request, the Democratic staff of the Senate Committee on 
Veterans' Affairs surveyed more than 200 VA community-based outpatient 
clinics nationwide to evaluate the success, capacity, and quality of 
care in these clinics. This self-reported information from individual 
clinics offers Congress and VA an opportunity to assess services 
provided by the various clinics, and to determine where improvements 
can be made to ensure that veterans receive the best possible care. The 
Democratic committee staff report concludes that, although all clinics 
reported offering primary care, services varied markedly by clinic and 
by geographic location.
  VA's 22 regional network directors, rather than VA Headquarters, hold 
responsibility for activating, operating, and overseeing the community 
clinics. Although this provides flexibility to local VA managers, the 
variations in services described by clinic staff appear to result from 
varied management practices rather than deliberate adaptations to 
community needs.
  For example, staffing levels did not appear to be related to the 
number of patients seen, and varied among clinics and among networks. 
Some clinics served about 5,000 patients in the first half of fiscal 
year 2000 with the equivalent of 15 full-time health care providers, 
while others served the same number of patients with only six full-time 
staff. Some clinics operated with fewer than two full-time employees.
  Variations in staffing translated into differences in the types and 
levels of services provided, including basic mental health care. Less 
than half of the clinics surveyed offered even minimal mental health 
care, an issue of concern as VA continues to close its inpatient mental 
health care clinics. In several areas of the country, waiting times for 
an appointment for primary care ranged from 30 to 150 days. More than 
60 percent of the community clinics lacked equipment and personnel to 
respond to a cardiac emergency, an issue of patient safety.
  VA's lack of a consistent, nationwide system for collecting and 
analyzing information on health care outcomes and treatment costs is an 
obstacle to measuring the success of VA's outpatient clinics. VA must 
develop tools to allow community clinics to monitor health outcomes, so 
that veterans can depend on a system that not only meets their needs 
but continues to improve their health status. Clinics must be able to 
combine this information on health outcomes with accurate data about 
costs of treatment, so that VA can ensure the effective and efficient 
use of resources at all clinics.
  I certainly do not expect community clinics to offer the full range 
of services available in a large medical center. However, it is 
reasonable to assume that a veteran seeking primary care through a VA 
outpatient clinic should be able to expect a minimum standard package 
of services and an acceptable quality of care, regardless of geographic 
location. Oversight by VA headquarters and by Congress is essential to 
ensuring consistency in the services and quality of care offered to 
veterans through community clinics.
  I have forwarded a copy of this report to VA Secretary Anthony 
Principi, and I look forward to working with him to make certain that 
veterans who turn to VA's community care clinics can expect not just 
access, but excellence.
  I ask unanimous consent that the text of the executive summary of the 
Democratic committee staff report be printed in the Record.
  There being no objection, the summary was ordered to be printed in 
the Record, as follows:

  Staff Report on Community-Based Outpatient Clinics in the Veterans 
         Health Administration, Department of Veterans Affairs

    (Prepared by the Democratic staff of the Committee on Veterans' 
  Affairs, United States Senate, for Senator John D. Rockefeller IV, 
                      Ranking member, May 3, 2001)


                           executive summary

       Background--In 1996, Congress broke down the barriers to 
     developing an outpatient care network within the Department 
     of Veterans Affairs (VA) health care system. The Veterans' 
     Health Care Eligibility Reform Act of 1996 (Public Law 104-
     262) simplified eligibility rules, mandated uniformity in 
     services offered to veterans, and eliminated legal barriers 
     to the sharing of health care resources with other providers. 
     In response, VA has shifted emphasis from providing hospital-
     based care to treating more veterans in outpatient clinics. 
     Much of the new outpatient care is being provided in 
     Community-Based Outpatient Clinics (CBOCs), local, often 
     small clinics, some operated by VA staff, others managed by 
     contractors for VA.
       Responsibility for activation, operation, and oversight of 
     CBOCs rests with VA's 22 Veterans Integrated Service Networks 
     (VISNs) directors, contingent upon congressional approval. 
     Between 1996 and 2001, more than 250 CBOCs have been 
     activated, with the goal of improving access to care for many 
     veterans. CBOC staff may treat veterans in the community 
     clinic or refer them to the parent VA medical center for more 
     intensive treatment and then provide followup care through 
     the clinic.
       As a consequence of the establishment of the CBOCs and 
     other changes in response to the Eligibility Reform Act of 
     1996, more veterans are accessing primary care in the 
     outpatient setting. VA estimates that the total number of 
     annual outpatient visits (in all facilities) has increased 
     from 26 million to 42 million in the last 5 years. Of the 229 
     clinics that completed surveys for this report, total 
     outpatient visits in the first half of FY 2000 increased more 
     than 20% over the equivalent period in FY 1999.
       Democratic Staff Project--At the direction of Ranking 
     Member John D. Rockefeller IV, the Democratic staff of the 
     Senate Committee on Veterans' Affairs undertook an oversight 
     project to determine whether CBOCs have fulfilled their 
     potential to deliver high quality care to veterans in an 
     effective and efficient manner.
       To carry out this project, staff members designed a survey 
     questionnaire intended to obtain information regarding 
     capacity and performance directly from the clinics. This 
     survey requested information on operation and management 
     issues, staffing, hours of operation, patient load, 
     availability and timeliness of care, costs, and quality of 
     care. Staff mailed surveys directly to the 257 
     congressionally approved clinics for which valid mailing 
     addresses could be obtained--rather than to VISN offices or 
     to parent medical center directors--and compiled the results 
     for federal FY 1999 (October 1, 1998-September 30, 1999) and 
     the first two quarters of federal FY 2000 (October 1, 1999-
     March 31, 2000).
       Based on this self-reported information from individual 
     clinics, this report is intended to offer an opportunity to 
     assess services provided by the various clinics and to 
     determine where improvements can be made to ensure that 
     veterans receive the best possible care.
       Data Collection and Validity--VA programs frequently suffer 
     from flawed data collection and monitoring, and outpatient 
     care provided by CBOCs is no different. No single VA source 
     could provide Committee staff with accessible and objective 
     information on clinic services systemwide. Thus, the validity 
     of the information received via the surveys must rely solely 
     upon the precision and accuracy with which clinic staff 
     completed the questionnaire. Despite Committee staff efforts 
     to design unambiguous questions regarding basic operational 
     parameters, the responses lacked uniformity. Some

[[Page 6940]]

     respondents indicated that the requested data for specific 
     questions had never been properly collected or could not be 
     accessed. Because a site audit of each clinic was beyond the 
     scope of Democratic Committee staff resources, this report 
     relies solely on self-reported data, with caveats for 
     incomplete or subjective responses noted.
       Findings and Conclusions--While community-based clinics 
     appear to offer an appropriate avenue for increasing 
     veterans' access to care, the unevenness of responses to the 
     staff survey precludes any generalized conclusions on the 
     collective success, capacity, and quality of these clinics. 
     The available data show wide variety in every possible 
     parameter of clinic function, both within and among networks. 
     This variability, which suggests a significant lack of 
     uniformity among the CBOCs, prevents easy summaries or simple 
     solutions for possible deficits.
       The flexibility inherent in the decentralized VA health 
     care system has allowed network and medical center directors, 
     rather than VA Headquarters, to map the course of VA's 
     community-based outpatient care. While this arrangement does 
     not preclude provision of excellent health care in individual 
     clinics and does present the opportunity to tailor services 
     to each community's demands, the significant variations in 
     operational standards described by clinic staff appear to 
     reflect varied management practices rather than deliberate 
     adaptations to community needs.
       Based on the variability in services--and in the vocabulary 
     for describing operational standards--the Democratic 
     Committee Staff can only infer that VA has not established a 
     systemwide baseline for the minimum acceptable service levels 
     in CBOCs. Community clinics should not be expected to offer 
     identical or completely inclusive services. However, veterans 
     accessing primary care through VA outpatient clinics should 
     be able to depend upon a minimum standard package of 
     services, regardless of geographic location, and on an 
     acceptable level of quality of care. Also, the Congress 
     should be able to expect an effective and efficient use of 
     resources at all CBOCs.
       Specific findings include the following: The number of FTEE 
     (full-time employee equivalents) providing primary care 
     varied markedly among clinics and did not appear to be linked 
     consistently to the patient load. Staffing levels for clinics 
     serving about 5,000 patients in the first half of FY 2000 
     ranged from 6 to 15 FTEE. Some clinics operated with fewer 
     than two FTEE, raising significant concerns about the ability 
     of such a limited staff to offer high quality health care 
     while performing administrative tasks and monitoring quality 
     of care.
       VA does not provide the same services in all clinics. 
     Variations in staffing translate into variations in the types 
     and levels of services provided, including basic mental 
     health care, both preventive and counseling services, and 
     overall hours of service. Veterans in different regions 
     should be able to expect a standard basic package of 
     services.
       Community clinics have not eliminated long waiting times to 
     obtain an appointment and to receive treatment in every 
     network in accordance with VA goals. The longest actual 
     waiting time for an appointment exceeded 30 days in 18 
     networks. Only a few clinics reported having a defined policy 
     for accepting and scheduling ``walk-ins.''
       Many community clinics lacked equipment and personnel to 
     respond to a cardiac emergency, an issue of patient safety. 
     Each clinic should have, at minimum, an automated external 
     defibrillator and staff trained in its use. Only 38% of 
     clinics reported having the staff and equipment necessary in 
     the case of a cardiac emergency.
       Community clinics have not offered sufficient outpatient 
     mental health care to compensate for the loss of VHA 
     impatient programs. The number of VA medical facility beds 
     available for impatient mental health care has declined 
     steadily over the last two decades. By the end of FY 2001, VA 
     anticipates reducing the numbers of patients treated in 
     inpatient psychiatric care programs by 56% from the level 
     treated in FY 1995. Outpatient mental health care programs 
     provide a complement to (although not a substitute for) acute 
     inpatient care, and can serve as a valuable community-based 
     tool in a comprehensive mental health care maintenance 
     regimen.
       If outpatient programs are to play a part in maintaining 
     systemwide capacity for mental health care treatment of 
     veterans, they must be accessible to veterans at the sites of 
     outpatient care. Yet, less than half of the clinics surveyed 
     reported offering any mental health care. Of the 229 clinics 
     that responded to the staff survey, only 50 reported that 
     they provided PTSD treatment, and only 42 reported offering 
     substance abuse treatment of any kind. Mental health care 
     FTEE constituted only a small fraction of the total clinic 
     staff in most networks.
       Clinics report a range of costs per patient visit, with the 
     average cost per visit within a network in FY 1999 ranging 
     from $27 to $290. Calculating the cost-effectiveness of 
     outpatient treatment requires a uniform method of calculating 
     actual costs, which VA currently lacks. Whether the variation 
     in patient visit costs reported by clinics represents varying 
     staff efficiency or differences in treating ``revenue-
     generating'' insured patients cannot be determined from the 
     data here.
       The lack of a coherent system for collecting, monitoring, 
     and analyzing quality of care data prevents evaluation of 
     community care success. Almost all clinics reported that they 
     document and monitor the quality of health care provided, but 
     the clinic staff who completed the surveys had widely varying 
     perceptions of what constituted a quality of care assessment. 
     The materials presented for documenting quality of care 
     ranged from medical checklists to patient satisfaction 
     surveys that focused largely on aspects of patients' physical 
     and emotional comfort in the clinic setting, rather than 
     health care-related criteria. None documented health 
     outcomes. Only 130 clinics reported sending any quality of 
     care reports (regardless of content) to the parent 
     facilities, and none received written feedback specific to 
     that clinic from the parent facilities. The complete lack of 
     a shared vocabulary for measuring quality of care prevented 
     any compilation of the data. One clinic operated by a 
     contractor responded that monitoring quality is not part of 
     its contract.
       The poor or absent measures of quality of care make the 
     effectiveness of the care provided by the clinics, variations 
     between contracts- and VA-operated clinics, and the effect of 
     staffing inequities impossible to judge. VA needs a 
     consistent set of tools that can be employed in outpatient 
     clinics systemwide to obtain meaningful quality of care 
     outcomes.

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