[House Hearing, 114 Congress]
[From the U.S. Government Publishing Office]







    OVERCOMING BARRIERS TO MORE EFFICIENT AND EFFECTIVE VA STAFFING

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

                                HEARING

                               before the

                         SUBCOMMITTEE ON HEALTH

                                 of the

                     COMMITTEE ON VETERANS' AFFAIRS
                     U.S. HOUSE OF REPRESENTATIVES

                    ONE HUNDRED FOURTEENTH CONGRESS

                             FIRST SESSION

                               __________

                          FRIDAY, MAY 15, 2015

                               __________

                           Serial No. 114-21

                               __________

       Printed for the use of the Committee on Veterans' Affairs




[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]


         Available via the World Wide Web: http://www.fdsys.gov
         
         
                                      ______

                         U.S. GOVERNMENT PUBLISHING OFFICE 

98-638                         WASHINGTON : 2016 
-----------------------------------------------------------------------
  For sale by the Superintendent of Documents, U.S. Government Publishing 
  Office Internet: bookstore.gpo.gov Phone: toll free (866) 512-1800; 
         DC area (202) 512-1800 Fax: (202) 512-2104 Mail: Stop IDCC, 
                          Washington, DC 20402-0001      
         
         
         
         
         
         
         
         
         
         
         
         
         
         
         
         
         
         
                     COMMITTEE ON VETERANS' AFFAIRS

                     JEFF MILLER, Florida, Chairman

DOUG LAMBORN, Colorado               CORRINE BROWN, Florida, Ranking 
GUS M. BILIRAKIS, Florida, Vice-         Minority Member
    Chairman                         MARK TAKANO, California
DAVID P. ROE, Tennessee              JULIA BROWNLEY, California
DAN BENISHEK, Michigan               DINA TITUS, Nevada
TIM HUELSKAMP, Kansas                RAUL RUIZ, California
MIKE COFFMAN, Colorado               ANN M. KUSTER, New Hampshire
BRAD R. WENSTRUP, Ohio               BETO O'ROURKE, Texas
JACKIE WALORSKI, Indiana             KATHLEEN RICE, New York
RALPH ABRAHAM, Louisiana             TIMOTHY J. WALZ, Minnesota
LEE ZELDIN, New York                 JERRY McNERNEY, California
RYAN COSTELLO, Pennsylvania
AMATA COLEMAN RADEWAGEN, American 
    Samoa
MIKE BOST, Illinois
                       Jon Towers, Staff Director
                Don Phillips, Democratic Staff Director

                         SUBCOMMITTEE ON HEALTH

                    DAN BENISHEK, Michigan, Chairman

GUS M. BILIRAKIS, Florida            JULIA BROWNLEY, California, 
DAVID P. ROE, Tennessee                  Ranking Member
TIM HUELSKAMP, Kansas                MARK TAKANO, California
MIKE COFFMAN, Colorado               RAUL RUIZ, California
BRAD R. WENSTRUP, Ohio               ANN M. KUSTER, New Hampshire
RALPH ABRAHAM, Louisiana             BETO O'ROURKE, Texas

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public 
hearing records of the Committee on Veterans' Affairs are also 
published in electronic form. The printed hearing record remains the 
official version. Because electronic submissions are used to prepare 
both printed and electronic versions of the hearing record, the process 
of converting between various electronic formats may introduce 
unintentional errors or omissions. Such occurrences are inherent in the 
current publication process and should diminish as the process is 
further refined.





                            C O N T E N T S

                              ----------                              

                          Friday, May 15, 2015

                                                                   Page

Overcoming Barriers to More Efficient and Effective VA Staffing..     1

                           OPENING STATEMENTS

Dan Benishek, Chairman...........................................     1
Julia Brownley, Ranking Member...................................     2

                               WITNESSES

Joan Clifford MSM, RN FACHE, Immediate Past President, Nurses 
  Organization of Veterans Affairs...............................     4
    Prepared Statement...........................................    37

Samuel V. Spagnolo M.D., President, National Association of 
  Veterans Affairs Physicians and Dentists.......................     5
    Prepared Statement...........................................    39

Jeff L. Morris J.D., Director of Communications and External 
  Affairs, American Board of Physician Specialties...............     8
    Prepared Statement...........................................    47

Rubina DaSilva PA--C, President, Veterans Affairs Physician 
  Assistant Association..........................................    10
    Prepared Statement...........................................    54

 Nichol L. Salvo DPM, Member and Employee, American Pediatric 
  Medical Association............................................    12
    Prepared Statement...........................................    63

Thomas Lynch M.D., Assistant Deputy Under Secretary for Health 
  for Clinical Operations, VHA, U.S. Department of Veterans 
  Affairs........................................................    27
    Prepared Statement...........................................    67

    Accompanied by:

        Elias Hernandez, Deputy Chief Officer for Workforce 
            Management and Consulting, VHA, U.S. Department of 
            Veterans Affairs

    And

        Donna Gage Ph.D., RN, NE-BC, Chief Officer of Nursing 
            VHA, U.S. Department of Veterans Affairs

                        STATEMENT FOR THE RECORD

American Counseling Association..................................    77
American Federation Government Employees.........................    80
The American Legion..............................................    93
Partnership for Public Service...................................    98
Merritt Hawkins..................................................   108

 
    OVERCOMING BARRIERS TO MORE EFFICIENT AND EFFECTIVE VA STAFFING

                              ----------                              


                          Friday, May 15, 2015

             U.S. House of Representatives,
                    Committee on Veterans' Affairs,
                                    Subcommittee on Health,
                                                   Washington, D.C.
    The subcommittee met, pursuant to notice, at 11:09 a.m., in 
Room 334, Cannon House Office Building, Hon. Dan Benishek 
[chairman of the subcommittee] presiding.
    Present:  Representatives Benishek, Roe, Coffman, Wenstrup, 
Abraham, Brownley, Takano, Kuster, and O'Rourke.
    Also Present: Representative Costello.

           OPENING STATEMENT OF CHAIRMAN DAN BENISHEK

    Dr. Benishek. The subcommittee will come to order.
    Before we begin, I would like to ask unanimous consent for 
my friend, colleague, and member of the full committee, 
Congressman Ryan Costello from Pennsylvania, to sit on the 
dais, participate in today's proceedings.
    Without objection, so ordered.
    Thank you for joining us today for today's subcommittee 
hearing, ``Overcoming Barriers to More Efficient and Effective 
VA Staffing.''
    As a physician who worked fee-for-service at the Iron 
Mountain VA, Department of Veteran Affairs, Medical Center for 
about 20 years, I know firsthand how rewarding it can be to 
take care of veterans at the VA. And having the privilege of 
caring for veterans on a daily basis was really wonderful for 
me.
    Regardless of how fulfilling VA employment often is, the 
Department's ability to effectively and efficiently recruit and 
retain qualified medical professionals to treat veterans is 
seriously fractured. For example, in my district, the Sault 
Ste. Marie Community-Based Outpatient Clinic in Sault Ste. 
Marie, Michigan, has not had a physician on staff for at least 
2 years.
    VA has attributed that to the difficulty of recruiting 
physicians in rural areas. And while I understand that 
difficulty, I think VA's overly bureaucratic hiring process is 
also a significant factor in its inability to recruit a 
physician for multiple years running.
    The Iron Mountain VAMC, the Sault Ste. Marie CBOC's parent 
facility, was unable to post the opening for a physician 
directly. Instead, all job postings under Iron Mountain's 
purview are filtered through a human resource office in 
Milwaukee, Wisconsin, several hours away in another State. In 
my understanding, all VISN 12 facility job postings are run 
through this one office in Milwaukee.
    What is more, despite repeated assurances by VA officials 
the Department was actively recruiting for a physician in the 
Sault--in Sault Ste. Marie--we call it ``the Sault'' in 
Michigan--I have yet to see a single advertisement for that 
position besides a blurb on the hospital's Web site, leaving me 
to wonder whether the VA knows what effective recruiting is 
supposed to look like.
    As important as effective recruitment is, effective 
retention of existing employees is also critical. But according 
to the 2014 Best Places to Work survey published by the 
Partnership for Public Service, the number of VA employees 
resigning or retiring has risen every year since 2009. And it 
is not hard to see why: The survey results rank VA 18 of 19 
large agencies overall, 18 of 19 in effective leadership, 19 of 
the 19 in pay, with the Department's overall score last year 
being the lowest VA has received since the report was first 
published in 2003.
    When a VA medical center is improperly staffed and when a 
qualified candidate chooses to look elsewhere for work or when 
an existing provider makes the decision to leave the VA, it is 
our veterans that lose out. The growing physician shortage is 
causing the healthcare marketplace to become more and more 
competitive, with the Association of American Medical Colleges 
projecting a 91,000-physician shortfall by 2025.
    If the VA is going to keep pace with the private sector in 
recruiting and retaining the high-quality providers that our 
veterans deserve, immediate action must be taken to improve 
retention of existing staff and ensure that qualified 
candidates for new or vacant positions are quickly identified, 
recruited, hired, and brought aboard.
    Critical to that and to all of VA's plans regarding the 
delivery and quality of care is making sure that those on the 
front lines providing direct patient care are not only involved 
but leading the efforts to make the VA healthcare system 
stronger.
    To that end, I am proud to have representatives from the 
National Association of VA Physicians and Dentists, the VA 
Physician Assistant Association, and the Nurses Organization of 
VA on our first panel of witnesses today.
    The input you as well as the rest of our witnesses will 
provide about the daily reality you and your members face at VA 
facilities across the country every day is invaluable. I thank 
you and all of our witnesses for being here this morning.
    And I now yield to the Ranking Member, Ms. Brownley, for 
any opening statement she may have.

       OPENING STATEMENT OF RANKING MEMBER JULIA BROWNLEY

    Ms. Brownley. Thank you, Mr. Chairman. And thank you for 
calling this hearing today on VA staffing.
    Section 301 of the Veterans Access, Care, and 
Accountability Act, signed by the President last year, mandated 
the VA shall submit a report assessing the staffing of each 
medical facility of the Department. This hearing will 
investigate this report and how the VA is doing in evaluating 
the staffing needs around the country in respect to the care of 
our veterans.
    In its report, the VA cites the need for an additional 
approximately 10,000 full-time employees to supplement the 
approximate 180,000 employees that currently work in veterans' 
healthcare. I am looking to find out from the VA how both 
numbers were arrived at.
    One issue is that last year Secretary McDonald quoted a 
number of 28,000 positions needed to fully staff VA healthcare. 
Now we are down to just over 10,000. The staffing report 
concurs with the inspector general's report listing the top 
five occupations that are most critical: medical officer, 
nurse, physician assistant, physical therapist, and 
psychologist.
    One occupation not listed because it is not technically 
healthcare-related is human resources. These are the people 
that hire and fire and generally keep a facility fully staffed. 
I am interested in hearing how the VHA will be streamlining its 
hiring process and getting more people to work in a reasonable 
timeframe to treat our veterans.
    Veterans in my congressional district face barriers to 
accessing care due to VA staffing issues. Ventura County is 
home to over 47,000 veterans, and our local CBOC, which 
provides primary care and mental health services, struggles 
with staff retention. There are high turnover rates for 
physicians and medical support staff.
    The CBOC's primary-care team is down to just one physician, 
two nurse practitioners, and one physician assistant. In 
addition, our county veteran service officer is concerned that 
veterans are not using important wraparound services because 
there is no primary-care social worker on staff. Over the past 
5 years, the number of veterans seeking mental healthcare at 
the CBOC has doubled. And the VA has been working hard to meet 
the growing demand, but we still seem to be in a place where we 
are not fully staffed.
    I know that staffing issues facing Ventura County are ones 
that can be found across the VA system. I look forward to 
hearing how VA is using the funding provided in the Choice Act 
to increase the Department's workforce and high-demand 
occupations so that the Nation's veterans have timely access to 
the high-quality professional care that the VA is known for.
    Thank you, Mr. Chairman, and I yield back the balance of my 
time.
    Dr. Benishek. Thank you, Brownley.
    Joining on our first panel is Joan Clifford, immediate past 
president of the Nurses Organization of Veterans Affairs; Dr. 
Samuel Spagnolo, the president of the National Association of 
Veterans Affairs Physicians and Dentists; Rubina DaSilva, the 
president of the Veterans Affairs Physician Assistant 
Association; Jeff Morris, the director of communications and 
external affairs for the American Board of Physician 
Specialties; and Dr. Nichol Salvo, member and employee of the 
American Podiatric Medical Association.
    Ms. Clifford, we will begin with you. Please proceed with 
your testimony.
    We allow everybody 5 minutes. So there should be a little 
light there that when it goes red that means you are up. 
Thanks.

          STATEMENT OF JOAN CLIFFORD, MSM, R.N., FACHE

    Ms. Clifford. Thank you.
    Chairman Benishek, Ranking Member Brownley, and members of 
the subcommittee, on behalf of the nearly 3,000 members of the 
Nurses Organization of Veterans Affairs, NOVA, I would like to 
thank you for the opportunity to testify on today's important 
and timely subject, VA staffing.
    As the Department of Veterans Affairs undergoes systemwide 
reorganization, to include the many challenges of implementing 
the Veterans Access, Choice, and Accountability Act, staffing 
must be at the forefront of its evaluation.
    I am Joan Clifford, deputy nurse executive at the VA Boston 
Healthcare System, and I am here today as the immediate past 
president of NOVA. NOVA is a professional organization for 
registered nurses employed by VA. NOVA's focus is professional 
issues.
    NOVA is uniquely qualified to share its views on the 
ability of VA to efficiently and effectively recruit, onboard, 
and retain qualified healthcare professionals to treat our 
veteran patients. As VA nurses, we are in the medical centers, 
community-based outpatient clinics, and at the bedside every 
day.
    We have identified retention and recruitment of healthcare 
professionals as a critically important issue in providing the 
best care anywhere for our veterans, and we would like to offer 
the following observations.
    NOVA believes that the underlying issues reside in the lack 
of a strong infrastructure for human resources, insufficient 
nursing education opportunities, and the complex application 
system, namely USAJOBS, that VHA uses for hiring staff.
    VHA is facing a shortage of corporate experience and 
insufficient HR staffing to support the multiple priorities 
required for hiring healthcare professionals. The complex 
hiring process, with systems that do not interface, lead to 
extended waits for job offers. At times, this results in 
candidates accepting non-VA jobs and puts VA back in the hunt 
for qualified candidates.
    Limited knowledge of direct hiring process for registered 
nurses, resulting in unnecessary recruitment delays, and VA 
processes and policies for obtaining recruitment and retaining 
incentives contribute to delays in hiring personnel. 
Reclassification and downgrades of some occupations, such as 
surgical technicians, who are brought in at the GS-7 level and 
have recently been downgraded to GS-5, are making it impossible 
to competitively retain and recruit. A lack of knowledge on how 
to maximize the locality pay law has resulted in inconsistent 
application of the law, an obstacle to hiring and retention.
    NOVA asks that the ceiling on nurse pay be increased to 
prevent compression between the grades in order to remain 
competitive.
    Ensuring an infrastructure to sustain programs that produce 
nursing graduates who honor and respect veterans' programs is 
vital. The Office of Academic Affairs has supported a wonderful 
R.N. residency program across some VAs, but funds are limited, 
potentially impacting the recruitment of future hires who flock 
to these programs.
    The nurse practitioner residency program is currently a 
pilot and will require continued funding to pay for resident 
stipends and educational infrastructure. NOVA believes it is a 
good investment, as hiring nurse practitioners will increase 
access and enable additional services to veterans needing care 
nationwide.
    Ongoing support for tuition reimbursement and loan 
forgiveness programs to help nurses defray the cost of 
education if they work for VHA and support for VA nursing 
academic partnerships is needed.
    An area of concern is the use of advanced practice nurses, 
which at this time is subject to State laws in which the 
facility is located. VHA is advocating full practice authority, 
which would result in all advanced-practice-registered nurses 
employed by the VA to be able to function to the full extent of 
their education, licensure, and training, regardless of the 
State in which they live and work.
    Legislation has been introduced, H.R. 1247, the Improving 
Veterans Access to Care Act of 2015, which is the model already 
practiced by the Department of Defense, Indian Health Service, 
and Public Health Service systems. NOVA, together with other 
national nursing organizations, are calling on Congress to 
support this legislation, which would begin to address critical 
needs within VA facilities by improving wait times and access 
of care to all veterans.
    VA employs over 90,000 nursing personnel, which is about a 
third of its healthcare workforce. NOVA believes that there is 
no greater time to have representatives from the Office of 
Nursing Services at the table as VA reorganizes the way it 
provides care and services to America's heroes.
    Improvements and careful review of the process of 
downgrades across VA, increased training and utilization of the 
locality pay law, revising the cap on the R.N. pay schedule to 
eliminate compression, as well as establishing a more user-
friendly application process and supporting human resource 
offices across the Nation, will go a long way towards 
correcting the challenges VA faces with staffing.
    NOVA once again thanks you for this opportunity to testify, 
and I would be pleased to answer any questions from the 
committee.

    [The prepared statement of Ms. Joan Clifford appears in the 
Appendix]

    Dr. Benishek. Thank you very much, Ms. Clifford.
    Dr. Spagnolo, please go ahead.

             STATEMENT OF SAMUEL V. SPAGNOLO, M.D.

    Dr. Spagnolo. Mr. Chairman, we have submitted a written 
testimony, and I would ask that you have that entered into the 
record. And I will try to keep my few comments here fairly 
brief.
    Thank you for having us here, and thank the distinguished 
members of the committee for having us here. We certainly 
appreciate it.
    I am here as a practicing physician, with more than four 
decades with the VA. And I am here also as the president of the 
National Association of VA Physicians and Dentists, usually 
referred to as NAVAPD. I might add, too, that I am a veteran, 
having served for 2 years of Active Duty in the United States 
Public Health Service.
    The National Association of VA Physicians and Dentists is a 
501(c)(6) nonprofit organization that is dedicated to improving 
the quality of patient care in the VA healthcare system and 
ensuring the doctor-patient relationship is maintained and 
strengthened. I appear today in pursuit of that purpose.
    This year is NAVAPD's celebration of its 40th year. NAVAPD 
believes that a key means of enhancing care of veterans is by 
employing the best physicians and dentists. NAVAPD believes it 
is essential for physicians to be involved in decisions 
regarding delivery and quality of healthcare.
    During my many years with the VA, I have witnessed 
firsthand many changes in the VA--some good, some not so good. 
I have had the opportunity to meet nearly all the Secretaries 
of the VA over the last 40 years. I got to know several of them 
very well, and a few I have seen as patients. I believe all of 
these individuals have been good people and all of the best 
intentions. I am sure Secretary McDonald, who I have also met 
with, also has good intentions.
    Notwithstanding the good intentions of these good people, 
however, the role of the physician within the system as a 
leader of medical care has greatly diminished over this same 
period. Today, most physicians and dentists feel like their 
opinions are neither helpful nor requested. At many centers, 
physicians and dentists are no longer even considered 
professionals but referred to simply as ``workers.'' These 
observations come from our members--VA docs and dentists, men 
and women who want to help improve veterans' care.
    In the late 1960s and 1970s, nearly all VA medical centers 
were led by directors who were physicians. Today, very few 
medical centers have physician directors. The position now 
called the VA Under Secretary of Health was known as the chief 
medical director. At that time, there was a direct line from 
the chief of staff at the medical center to the chief medical 
director. Issues of delivery and quality of medical care were 
raised and addressed by medical professionals. Today, chiefs of 
staff report to a clinical specialist at the VISN centers.
    In more recent times, there has also been a strong movement 
to eliminate the need even to have a physician in the role of 
Under Secretary of Health. I ask, would it be wise or even 
possible to run the Defense Department without generals and 
admirals in leadership positions? We are not saying there is no 
role for nonphysicians in the administration of hospitals or 
medical care. We are saying, however, that medical judgment 
should be based on years of education and patient care.
    Physicians are being loaded with additional duties more 
appropriate for nonphysicians, such as typing, filing letters, 
followup calls, patient reception, and preparation. Similarly, 
it is not cost-saving nor efficient to have physicians 
routinely escort patients from waiting rooms to exam rooms and 
having them help the patients get undressed.
    There is a growing trend to add nonphysicians, and there is 
a growing concern that a veteran may never be seen or treated 
by a physician while in the VA healthcare system. Veterans are 
seen by non-M.D. doctors without ever realizing they have not 
seen a medical doctor. We believe this is dangerous for 
patients and their families, and it may also raise some ethical 
issues.
    The VA is currently considering a change in its nursing 
handbook. Under the proposed handbook, there will no longer be 
any physician oversight for the process of sedation and 
providing operating room anesthesia by certified registered 
nurse anesthetist. The proposed change provides no guarantee 
this will provide safer patient care. Additionally, LPNs with 
little or no psychiatric experience are taking the place of 
psychiatrists during intake counseling and assessments in some 
psychiatric departments.
    Taking care of patients and providing excellent care has a 
lot to do with providing the basics and using a lot of common 
sense. For example, when patients are asked what is important 
to them, you will hear simple, straightforward, commonsense 
questions, such as: Will I be admitted quickly? Is the room 
clean? Is there a bathroom in the room? Does the call button 
work, and does someone answer and arrive quickly when I need 
them? Does everyone speak so I can understand them? If I need 
help to eat, will there be somebody there to help me? Do my 
doctors and nurses spend time explaining things so that I can 
understand what is happening? Unfortunately, patient surveys 
indicate that none of the above questions are being answered 
very well in the VA.
    Although the crisis last year in VA did focus on access to 
care, this is but one small piece of the total package. Getting 
timely initial access is of little value if it takes months to 
get your hip replaced or have a lung cancer removed or a 
colonoscopy screening because there may not be sufficient 
physicians or adequate access to the operating room. Timely 
access must be assured throughout the course of care, not just 
on the initial visit.
    VA is referred to as a healthcare system. At best, it is a 
collective of hospitals and other medical facilities operating 
under a common umbrella. The operational standards at every 
facility appear to be different. There must be unification and 
simplification of process across the organization to achieve an 
order of efficiency and common outcomes. When you have seen one 
VA, you have only seen one VA.
    In this regard, we have seen no recent operational 
structural changes that would increase the efficiency of 
physicians and dentists in the VA. Changes announced by the 
current Secretary are not being consistently implemented in 
local facilities, perhaps because the facility leaders have not 
understood that these changes are mandatory----
    Dr. Benishek. Doctor, you will have to clean up your time 
here.
    Dr. Spagnolo. I am--one sentence left.
    Dr. Benishek. Okay. Good.
    Dr. Spagnolo. Hearings like this are important and helpful, 
and the VA appreciates the--NAVAPD appreciates the opportunity 
to be here today. We want to help fix the medical care problem. 
The unfortunate truth, however: It is far easier to throw money 
at the situation than it is to fix it.
    Thank you, Mr. Chairman.

    [The prepared statement of Dr. Spagnolo appears in the 
Appendix]

    Dr. Benishek. Thank you, Doctor.
    Mr. Morris, you have 5 minutes to come across with your 
testimony.

               STATEMENT OF JEFF L. MORRIS, J.D.

    Mr. Morris. Chairman Benishek, Ranking Minority Member 
Brownley, and distinguished members of the Health Subcommittee, 
the American Board of Physician Specialities thanks you for the 
examining the issue of overcoming barriers to more efficient 
and effective VA staffing.
    Veterans should never be shortchanged in their medical 
care. Recruiting qualified and highly skilled physicians to 
work within the VA health system is needed now more than ever. 
What many do not know is that physician politics, along with 
existing discriminatory and monopolization practices of the 
American Board of Medical Specialties, are keeping excellent 
physicians out. What is indefensible is that they are not 
denied because of their training, education, or experience. 
These highly skilled physicians are being denied employment 
solely based on their choice in board certification.
    Dr. Robert M. Weinacker is a prime example of this very 
discrimination going on within the Administration. Dr. 
Weinacker, a veteran himself, was a Green Beret and former 
member of Special Forces. He was even handpicked as battalion 
surgeon to lead the medical treatment of 400 of our Special 
Forces. He wanted to work at the VA. He applied for seven 
positions and was never even called back for an interview.
    This was not due to his training. Dr. Weinacker, a graduate 
of the University of Alabama Medical School, is residency-
trained in radiation oncology and is a fellow of the American 
Academy of Radiology. In addition to his medical profession, 
Dr. Weinacker is also an attorney in hospital administration, 
with a focus on waste, fraud, and abuse.
    The only barrier that prevented Dr. Weinacker from working 
at a VA was his choice in certification. He chose--each 
position required ABMS certification only. Dr. Weinacker chose 
ABPS, and, because of that choice, he is consistently denied 
the opportunity to take care of his fellow veterans.
    We are here to ask the VA to cease their discrimination of 
ABPS physicians such as Dr. Weinacker. Behind this 
discrimination is the fact that most people do not understand 
what board certification is. Board certification is a choice 
and an indicator that a practitioner has demonstrated their 
mastery of the core body of knowledge and skills in their 
chosen specialty.
    Currently, there are three recognized multispecialty 
certifying bodies: the American Board of Medical Specialities, 
the American Osteopathic Association, and the American Board of 
Physician Specialties. ABMS, the largest of the 3, is made up 
of 24 individual specialty bodies, making many believe that 
they are all different entities. This structure has hidden the 
monopoly that ABMS has been establishing, making many believe 
they are the only one.
    ABMS is not the only higher standard board. There are 
others that meet or exceed their standards. In fact, ABPS is 
the only one of the three to have received an independent 
affirmation of the high standards of its exams through an 
exhaustive review process performed by Castle Worldwide.
    Since 1994, ABPS has approached the Department regarding 
these discriminatory staffing issues creating barriers to 
hiring skilled physicians. Each time, the Administration would 
protect the ongoing monopoly and respond that they had no plans 
to recognize anyone else.
    In 2011, ABPS returned to the Administration to stop the 
discrimination and further explain that we were a part of the 
current standard of certification. They again refused to see 
the issues.
    All these discussions were led by former Under Secretaries 
of Health Drs. Petzel and Jesse, along with Dr. Karen Sanders--
all board-certified by the very same organization keeping ABPS 
and other highly skilled physicians out.
    What is most confusing is that, under the GI bill, ABPS has 
been reviewed and approved by the U.S. Department of Veterans 
Affairs. Yet they stated to us that it does not mean they have 
to accept it. The VA reimburses for ABPS board certification 
but will not recognize it for hiring or promotion.
    The Administration also stated to us that board 
certification is not a requirement, that it is left to the 
discretion of the local VA. However, this has not been the 
case. According to USAJOBS, there are over 1,000 open physician 
positions. Most blatantly discriminate by requiring ABMS/AOA 
only, limiting the ability to fill much-needed positions.
    Only a few hospitals recognize ABPS and have hired them to 
fill their staffing needs. The Kansas City VA is a good example 
of this, providing a higher level of care. Some also have hired 
ABPS physicians, but ABMS continuously creates a hostile work 
environment and openly discriminates against them. Many of 
those physicians are not here today because they feared 
retribution or loss of their jobs.
    ABPA wishes to contribute to solutions to ensure that 
veterans receive the highest quality of care. A directive from 
the Office of the Secretary of the VA needs to be in place that 
creates antidiscrimination policy, that clearly defines board 
certification and goes beyond just the acceptance of ABMS/AOA. 
Job listings should no longer allow for one specific board over 
another.
    We also ask that a quarterly reporting structure be 
developed. Whereas VA healthcare institutions report on 
applications received, the denial and hiring of physicians and 
all applicant boards be identified, having identified 
individuals accountable for this oversight--all done in a 
similar manner as corporations are required to identify and 
ensure minority hiring. This will allow for a transparent 
credentialing process, and local VA medical centers will be 
held accountable.
    Thank you again for this opportunity. The ABPS looks 
forward to working with you to improve hiring practices and end 
the discrimination. Most importantly, our veterans' health, 
safety, and care must be placed before physician politics and 
the egos of a few. It is what they deserve.

    [The prepared statement of Mr. Jeff Morris appears in the 
Appendix]

    Dr. Benishek. Thank you, Mr. Morris.
    Ms. DaSilva, you are up next.

               STATEMENT OF RUBINA DaSILVA, PA-C

    Ms. DaSilva. Chairman Benishek, Ranking Member Brownley, 
and other members of the Health Veterans' Affairs Subcommittee, 
on behalf of the entire Veterans Affairs Physician Assistant 
Association, we really appreciate the invitation to provide 
this testimony before you today.
    The PA profession has a very special and unique 
relationship with veterans. The PA profession came into 
existence in the 1960s due to the shortage of primary-care 
physicians in the United States. The first graduates of the 
Duke University program in 1967 were former Navy hospital 
corpsmen.
    The VA was the first employer of the PAs and, to this day, 
is still the single largest employer of PAs in the country. 
Currently, there are 2,020 PAs working in the VA system. These 
PAs provide cost-effective, high-quality healthcare, working in 
hundreds of VA medical centers and outpatient clinics. In the 
VA system, about a quarter of all primary-care patients are 
treated and seen by a PA. Approximately 32 percent of those PAs 
are veterans, including myself. I am a former Navy hospital 
corpsman.
    The OIG report of January 2015 conducted a determination of 
the VA occupations with the largest staffing shortages, as 
required by the Veterans Choice Act. OIG determined that PAs 
were the third critical occupation on the list compared to all 
others.
    According to the National Workforce Succession Planning of 
2015, next year, in 2016, 37 percent of PAs are eligible to 
retire. This workforce loss will result in approximately a loss 
of 1.15 million veteran eligible patient care appointments. In 
2014, PAs had the highest total loss rate of 10 percent, more 
than any of the other top 10 occupations deemed difficult to 
recruit and retain.
    Utilizing the VA provisions of the Veterans Choice Act of 
2015, the VA reports no current plans for recruiting for new PA 
positions and for retaining an optimal PA workforce. They are 
setting goals to hire only physicians and nurses, as they 
interpret the law, and so not including the PA workforce.
    Some facilities are not posting for PAs at all under the 
Veterans Choice Act. Of the total postings nationally for PAs, 
there are only 83. This method effectively eliminates 50 
percent of eligible applicants. And when medical centers or 
CBOCs do not post for PAs, the centers send a message that PAs 
and PA veterans should not and cannot apply, even though 
military PAs often have higher levels of experience from 
frontline battlefield care.
    The discrepancy in salary, benefits, and education debt-
reduction programs between the civilian sector and the VA 
continues to be a recruiting and retention barrier.
    There are three types of providers within the VA that 
provide direct patient care: physicians, physician assistants, 
and nurse practitioners. Physicians are mandated a yearly 
market pay survey. Nurse practitioners, by virtue of being a 
nurse, are mandated under the yearly R.N. locality pay scale. 
PAs fall under a special salary rate. However, this is not 
mandated yearly. Some facilities have not performed a special 
salary survey for 11 years.
    Reporting in the results of the VISN 2014 Workforce 
Succession Plan, 88 VA main facilities report the reason that 
their VISN cannot hire PAs is because they cannot compete with 
the private-sector pay.
    The Secretary can convert physician assistants to covered 
positions and pay them pursuant to current public law. However, 
the VA has refused to pursue these steps to solve their current 
retention problems for PAs. The recommendation is Congress 
should legislate a mandate that the VA Under Secretary for 
Health include PAs in the nurse locality pay system under title 
38.
    For the education debt-reduction program, VAPA is also 
concerned that the use of recruitment incentives within the VA 
is at the discretion of the hiring facility and is not 
standardized across the VA system. During 2013, only 44 
physician assistants have received $319,000 in scholarships, 
compared to 705 registered nurses seeking to become nurse 
practitioners receiving scholarship awards totaling over $11 
million in support of NPs and NP programs.
    The recommendation is that VAs must advertise in all PA 
vacancy announcements so prospective applicants are aware of 
the education debt reduction--loan forgiveness. Move the 
program application process for accountability nationally since 
this is not a facility-funded but a VA-funded program.
    Next is the Independent Care Technician, the ICT, Program, 
also known as the Grow Your Own program. To assist returning 
OIF/OEF returning veterans, to include targeted scholarships, 
Grow Your Own mandates the VA shall appoint a PA ICT program 
director to coordinate the educational assistance necessary to 
be a liaison with PA university programs so these corpsmen and 
medics can follow the footsteps and become PAs.
    For recruitment, move all direct patient care positions to 
the National Recruiter/Workforce Office.
    In conclusion, Chairman Benishek, Ranking Member Brownley, 
and other members, as you strive to assure that veterans 
receive timely access to quality healthcare and demand more 
accountability into the VA healthcare system, we strongly urge 
the full committee to review the report and critical role of 
the PA profession and ensure the VA take immediate steps to 
address the current problems on a national level and not leave 
it to the VISN and local facilities to address the problem, as 
the OIG report shows the PA profession continuously moving up 
the list on critical occupations. The PA profession was borne 
from the military, and we need to continue that special 
relationship.
    On behalf of the entire membership of the Veterans Affairs 
Physician Assistant Association, I really appreciate this 
opportunity to testify here before you today and ask for your 
help in supporting the Nation's veterans.

    [The statement of Ms. Rubina DaSilva appears in the 
Appendix]

    Dr. Benishek. Thank you, Ms. DaSilva.
    Ms. DaSilva. Yes, sir.
    Dr. Benishek. Dr. Salvo, you are up.

               STATEMENT OF NICHOL L. SALVO, DPM

    Dr. Salvo. Chairman Benishek, Ranking Member Brownley, and 
members of the subcommittee, I welcome and appreciate the 
opportunity to testify on behalf of the American Podiatric 
Medical Association.
    I commend this subcommittee for its focus to assist and 
direct the Veterans Administration to effectively and 
efficiently recruit and retain qualified medical professionals 
and improve access to quality healthcare in the VA.
    I am Dr. Nichol Salvo, member and director of young 
physicians at APMA. I am also a practicing podiatrist, 
maintaining a without-compensation VA appointment. I am before 
you today representing APMA and the podiatric medical 
profession. While I do not represent VA, I do bring with me 
firsthand experience and knowledge of hiring practices within 
VA and knowledge of the widespread disparity between podiatric 
physicians and other VA physicians.
    Mr. Chairman, when the VA's qualification standards for 
podiatry were adopted in 1976, I was not yet born. Podiatry 
starkly contrasted with that of physician providers of the time 
and is a far cry from podiatric medicine as it is today.
    Unlike 39 years ago, current podiatric medical school 
curriculum is vastly expanded in medicine, surgery, and patient 
encounters. Back then, residencies were few and were not 
required. Today, there are mandated standardized comprehensive 
3-year medicine and surgery residencies to satisfy all of our 
graduates, with 77 positions housed within the VA, each 
requiring completion of a broad curriculum equitable to medical 
and osteopathic residency training.
    Today's podiatrists are appointed as medical staff at the 
vast majority of hospitals, and many serve in leadership roles 
within those institutions. Many of my colleagues have full 
admitting privileges and are responsible for emergency and 
trauma calls.
    The competency, skill, and scope of today's podiatric 
physicians has certainly grown from the podiatrists that 
practiced before I was born. Because of this, CMS recognizes 
today's podiatrists as physicians, and TRICARE recognizes us as 
licensed independent practitioners. That is today's podiatrist.
    We must also understand today's veteran. Veteran patients, 
often plagued by socioeconomic and psychosocial issues, are 
ailing, have more comorbid disease, and are of 
disproportionately poor health status compared to their 
nonveteran counterparts. These patients increase the burden of 
diabetic foot ulcers and amputations, and, as documented in my 
written testimony, almost 2 million veterans are at risk of 
amputation with underlying diabetes, sensory neuropathy, and 
nonhealing foot ulcers.
    This is my patient population. The veteran population is 
far more complex to treat than patients in the private sector 
as a whole. One of our major missions is amputation prevention 
and limb salvage, which provides a cost savings to VA and an 
integral role of the veteran quality of life.
    As part of the interdisciplinary team, podiatrists 
independently manage patients within our respective State scope 
of practice, and we assume the same clinical, surgical, and 
administrative responsibilities as any other unsupervised 
medical and surgical specialty.
    Despite this equality in work responsibility, there exists 
a marked disparity in pay and recognition of podiatrists as 
physicians in the VA. The majority of new podiatric hires have 
minimal experience and lack board certification. The majority 
of these new hires will separate from the VA within 5 years.
    I am speaking to you from personal experience, as I am one 
of the majority. I entered the VA without board certification, 
with less than 5 years of experience. I gained my experience, 
earned my board certification, and then separated from the VA 
to take a leadership position with my parent organization.
    While I will forever remain loyal to the veterans, which is 
why I still voluntarily treat patients in my local facility 
without compensation, I testify to the profound disparity.
    Legislative proposals to amend title 38 to include 
podiatric physicians and surgeons in the physician and dentist 
pay band have been submitted by the director of podiatry 
services annually for the last 10 years, and these proposals 
have been denied every single year, as were several requests 
for an internal fix, despite written letters of support from 
the former Under Secretary of Health Robert Petzel, M.D.
    Five years ago, APMA leadership made this issue a top 
priority. Since then, we have alerted the VA to our knowledge 
of this issue, and, in response, former Under Secretary Petzel 
created a working group with whom we have participated in 
several meetings and from whom we recently received 
acknowledgment of the need of a legislative solution to address 
this issue.
    In closing, I would like to state that oftentimes we find 
that the simplest solution is the best. I come before this 
committee today to respectfully request that Congress help the 
VA and its patients by passing legislation to recognize 
podiatric physicians and surgeons in the physician and dentist 
pay band.
    We believe that simply changing the law to recognize 
podiatry both for the advancements that we have made to our 
profession and for the contributions that we make in the 
delivery of lower-extremity care for our veteran population 
will resolve recruitment and retention problems for the VA and 
our veterans.
    Mr. Chairman and members of the subcommittee, thank you 
again for this opportunity. This concludes my testimony, and I 
am available for questions.

    [The statement of Dr. Nichol Salvo appears in the Appendix]

    Dr. Benishek. Thank you, Dr. Salvo. I appreciate it.
    I will yield myself 5 minutes for questions.
    Boy, there are a lot of questions I would like to get 
answered here today from many of you. I think I will start with 
Ms. Clifford, though, because I think you brought up something 
that is pertinent here.
    How long does the average hiring process take? How long is 
that time? And talk a bit more about the difficulty in getting 
people because they take a job somewhere else while the process 
is ongoing.
    Ms. Clifford. Right. So it is pretty variable, and it can 
go anywhere from 2 to 6 months or maybe more in some places.
    It is a very complex process. First, at most places, it 
will have to go through a resource committee for approval, 
which usually is the quickest part of the process. It then has 
to get posted on USAJOBS, so it has to be put in the proper 
format to be posted on that. And then we wait and get the 
certification of who has applied for that position. And then 
they have to go through all of these other processes we have, 
such as e-QIP, which is the background check. We have the----
    Dr. Benishek. In other words, like, 2 to 6 months----
    Ms. Clifford. Yes.
    Dr. Benishek [continuing]. In order to get hired. And so, 
like, the least amount of time is, like, 2 months.
    Ms. Clifford. I think 2 months would be considered a good 
hire--a quick hire.
    Dr. Benishek. Because I know that in the private sector it 
doesn't take--if you apply for a job, it doesn't take 2 months. 
They get hired in the private sector at the local hospital--I 
mean, in my experience. Do you have any experience with numbers 
in the private sector?
    Ms. Clifford. That is correct. I don't have any numbers, 
but I do know that that is what we hear from some of our 
candidates. And it will come to the point where they will say, 
I have another job offer, you know, how quickly can you tell me 
whether or not I can have it. Because they probably haven't 
even given notice to their other job, so it is another month 
after we even make the job offer to get them in the door.
    Dr. Benishek. Dr. Spagnolo, can you comment on the same 
question as far as the physician side of things? I know that, 
there is a lot of trouble with the qualifications or making 
sure that the person's background is right and on getting that 
right. But how does that process work in the VA, from your 
experience?
    Dr. Spagnolo. I would echo what you just heard. It takes 
sometimes up to a year to recruit a physician. I have heard 
them taking even longer.
    I also run the respiratory care department, and it is 
usually a year before we can hire a therapist, to get through 
all the processes and finally get them in. Working with H.R. is 
near impossible.
    Dr. Benishek. So this is all done through the H.R. 
department then? I mean, the physician hires, as well?
    Dr. Spagnolo. Well, you know, there is more than just the 
H.R. You have to get it approved by different committees and 
chairmen and hospital directors, and then it goes back and 
forth. It just takes forever.
    Dr. Benishek. Now, Dr. Salvo, you mentioned the podiatrist 
problem in the VA. At the VA that I worked at, the podiatrist 
was one of the busiest providers in the surgery clinic. I mean, 
they had a hard time keeping the podiatrists there long enough 
to do all the work you had to do.
    What is the difference in the payment? Are they not paid as 
physicians then? Can you explain that to me a little bit more?
    Dr. Salvo. Podiatry is on a different pay scale. 
Unofficially, I am aware that the pay scale ranges anywhere 
from $60,000 to a $100,000 less from other VA medical and 
surgical specialties, depending on what the specialty is.
    Dr. Benishek. Well, that would sort of explain why it is 
difficult to recruit.
    Ms. DaSilva, do you have anything to add on that, on that 
recruitment and difficulty-in-hiring question?
    Ms. DaSilva. I would agree with--it does take a long time. 
It takes about 6 weeks in the private sector, max, whereas in 
the VA system it can take up to 6 months.
    Dr. Benishek. Dr. Spagnolo, could you expand a little bit 
about my concern when I worked the VA was the fact that, the 
doctors weren't involved with making the decisions in 
departments that actually involved how the patient care is 
delivered. They were sort of told what to do by the 
administration and then left to do that.
    Can you expand on that thought? Do you agree with my 
thinking there? And what should be done about it?
    Dr. Spagnolo. Well, yes, we need to empower the physicians 
in the facilities. I think if you took people, in every VA 
facility, you took a dozen people in the facility who knew 
really what was going on, you could find out very quickly what 
was working and what wasn't working. You need to empower some 
of the nurses, you need to empower the physicians, get some 
real input on how to become more efficient and how to provide 
better care. I think that could be done very quickly.
    Dr. Benishek. Thank you.
    I am out of time, and I will yield to Ms. Brownley.
    Ms. Brownley. Thank you, Mr. Chairman.
    I know that the Secretary of the VA is really trying to 
make transformation at the VA. And I have heard him and others 
from the VA testify that we need to shift the VA from a rule-
based organization to a principle-based organization.
    And it sounds to me, based on the longevity of hiring 
people within the VA, it is the rules that are--because there 
are so many, is what slows the whole process down, that we 
would be better off following the practices of private industry 
in terms of hiring.
    Is that a fair assessment for nurses?
    Ms. Clifford. I would say so. There is a lot--it is very 
complex, lots of steps in the process from the human resource 
side, and that is what causes a lot of the delay.
    Ms. Brownley. So, for the nurses, unlike the physicians, 
the problems are predominantly within the human resources 
department and their rules. Hiring doctors, you go through 
human resources but have to go outside of human resources, as 
well?
    Yes, yes, yes, and yes?
    Ms. Clifford. I am not sure I understand the question about 
going outside.
    Ms. Brownley. So Dr. Spagnolo testified for longevity, in 
terms of hiring physicians, that it is within the human 
resources department but they also have to go outside of the 
human resources and, I presume, be interviewed by other 
physicians or other departments. And I am just wondering, for 
nurses, is the whole hiring process within the human resources 
department?
    Ms. Clifford. Well, the nurse managers or the supervisors 
make the decision of who they want to hire, and then the 
technical parts are all done by human resources.
    Ms. Brownley. And the same for physicians?
    Dr. Spagnolo. I can't tell you how many human resource 
officers I have seen go by in 40 years. But every new director 
that came to our facility in the last 40 years has said, ``My 
number-one priority is to fix H.R.'' It has never been fixed.
    Ms. Brownley. Mr. Spagnolo, your testimony was shocking, 
when you said sometimes veterans have medical appointments for 
care and leave not knowing that they did not see a physician or 
medical expert of any kind. That is pretty shocking testimony 
to me.
    And then when I hear some of the obstacles around physician 
assistants and the shortage there, I am not sure what to say, 
except we have a lot of improvements to make.
    But, I mean, do you think that that is a common occurrence, 
where a veteran comes for an appointment for medical services 
and never sees a physician?
    Dr. Spagnolo. Was the question do I think it is common?
    Ms. Brownley. Yes.
    Dr. Spagnolo. Yes, I think it is quite common.
    Ms. Brownley. And how do you think--you also said in your 
testimony that physicians are doing nonphysician care, like 
typing and filing and followup calls and helping patients 
change their clothes and patient reception, et cetera.
    How did that happen? How did those responsibilities become 
the responsibilities of the physician? Is it just because of 
the shortage of people in the operation, or are these specific 
responsibilities of a physician?
    Dr. Spagnolo. I don't know specifically how that has 
occurred over the years, but I can tell you that when I was a 
chief of staff a number of years ago, I used to say to our 
hospital director when he would come in and yell at me and say 
our docs aren't seeing enough patients--and I keep telling him 
that the reason they can't see patients is there is nobody in 
the clinic to assist them to see the patient.
    They have one examining room. They have to go get the 
patient. They have to help get the patient undressed. They have 
to see the patient. Then they have to write a note, usually on 
the computer nowadays. And they have to help the patient get 
dressed, and then they have to escort the patient out of the 
room.
    How many times in a day can you do that when you have no 
other help? You have nobody to help input data into the 
computer. You have no one to help you request drugs for 
patients into the computer. You are basically doing the 
physician, the secretary, the receptionist.
    It is very difficult to be efficient--not that the 
physicians don't want to be efficient. They would love to be 
efficient, but the system doesn't permit it. And when you talk 
to the administrators, they just glaze over. It gets the 
physicians extraordinarily frustrated. They would love to see 
more patients. Everybody would love to see more patients.
    Ms. Brownley. Thank you, Doctor.
    My time is up, and I yield back.
    Dr. Benishek. Dr. Roe, you are recognized for 5 minutes.
    Dr. Roe. Thank you, Mr. Chairman.
    And, Dr. Salvo, you really threw me off when I realized I 
have been a doctor longer than you have been alive.
    Dr. Spagnolo, I suspect you had the same sort of angst as I 
did.
    A couple of things I just want to go over very quickly. I 
have to run to the airport and catch an airplane. But, number 
one, I think you very clearly pointed out the loss of 
professionalism that is occurring.
    In my practice, I had an assistant, I had a nurse with me, 
I had three examining rooms. I could really see a lot of 
patients very efficiently and very well. You cannot see 
patients efficiently in that circumstance. It is impossible. 
You can't make you more productive when you have six jobs. And 
I think that very loss of professionalism has occurred.
    I think another thing that has occurred in the VA is that 
we have fewer M.D. providers as hospital administrators. If you 
have been in the trenches working, you understand exactly how 
that clinic works. I understand exactly how your clinic works 
or doesn't work. So I think that is one of the issues we have 
to deal with.
    And I think another question I have right quickly is, what 
is the retention problem? When you hire people, there is this 
huge turnover, both in nursing and on the medical side. What do 
you all see as that? Why is that? Is it the working conditions? 
The pay? I mean, there are a lot of things you have gone over, 
but why is that?
    Dr. Spagnolo. I will take a stab, and then it is yours.
    Ms. Clifford. Okay.
    Dr. Spagnolo. They come to work with great enthusiasm. Good 
people, they get put into these situations where, after 6 
months or a year, they just are frustrated, depressed, tired, 
nobody listens, and they leave. So your turnover rates, I don't 
know what they are nationally, but I know that in primary care 
some places have turnover rates of 100 percent every year.
    It is frustration. Primarily frustration, I would say.
    Dr. Roe. And--excuse me. Go ahead, Ms. Clifford.
    Ms. Clifford. So I would say it is, again, dependent on 
different facilities. To your point that people all come in 
with the best of intentions, but if you happen to be in an area 
that has a difficult time recruiting, then they are kind of 
always behind the eight ball. They are required to do a lot of 
overtime, or they are having lots of shift changes, and so 
people get frustrated and burnt out and leave. But in 
facilities that are able to maintain that, people stay because 
they stay for the mission of the VA.
    Dr. Roe. Two other quick questions.
    One is, from Mr. Morris' standpoint, is there a barrier? If 
you have a different--I am certified by the American Board, but 
are there barriers out there for other board certifications 
that you see that help reduce staffing? Is that a real issue 
that he brought up or not?
    And I guess, Dr. Spagnolo, you can answer it, or Mr. Morris 
can answer it, either one.
    And the second----
    Dr. Spagnolo. I think within certain----
    Dr. Roe. Let me throw the second one out so you can just 
answer it.
    You know, the Veterans Choice Act, which we spent a lot of 
time on and getting passed, provided $5 billion to increase 
staffing for the VA. Is that happening? Is that money being 
used that way?
    Those are my two questions.
    Dr. Spagnolo. If your question is, on the Veterans Choice 
Act, whether they are utilizing it, is that----
    Dr. Roe. Yes, sir.
    Dr. Spagnolo. I don't know how much they are utilizing it, 
to be honest with you. I don't know if the--I know that we have 
tried to have a few people go somewhere else. One had an 
artificial heart. And it was like a nightmare to get that done, 
because the facility that they were to go to had no experience 
with that.
    I can't tell you how it is across the VA. From what I hear, 
it is not very efficient. So if it is going to work, it has to 
be efficient.
    I would like to see within the VA more efficiencies and 
getting these procedures done more quickly. I mean, some 
physicians have no--their access to the operating room is 1 or 
2 days a week.
    Dr. Roe. Okay.
    That second--you know, with staffing less physicians, as 
Mr. Morris pointed out, is being boarded by somebody other than 
what I am boarded by, is that a barrier to hiring people?
    Dr. Spagnolo. Yes, I think it is a barrier.
    Dr. Roe. Is it a legitimate barrier, or is it----
    Dr. Spagnolo. I think it is a legitimate barrier in some 
situations.
    Dr. Roe. Okay.
    Any other comments on that? Have any of you--Dr. Salvo, 
have you seen that?
    Dr. Salvo. I am not--in my capacity as a WOC (Without 
Compensation) appointment within the VA, I have had to deal 
almost nothing with the Veterans Choice Act personally. That is 
purely administrative by other departments.
    Dr. Roe. Yes.
    Ms. DaSilva.
    Ms. DaSilva. Sir, I do want to say with the Veterans Choice 
Act, it has been interpreted to not include physician 
assistants by some facilities. So if you wanted to talk about 
increasing recruitment, if the jobs aren't even posted and 
physician assistants aren't even able to apply for those jobs, 
that is not going to increase access for care for veterans.
    Dr. Roe. Well, Just as I head out the door, it isn't really 
hard to figure out your needs when you just call the people 
scheduling appointments and find out you have a 6-month wait. 
It isn't rocket science. Look, I have been doing it for four 
decades, and you find out, and all of you there know, if you 
have a long waiting list for patients to come in, you need to 
hire people to take care of those waiting lists or make your 
shop more efficient. It is not complicated. I mean, I did it 
for years.
    And, I mean, the way I learned out if I needed anybody is I 
would go to church and somebody would say, I can't get an 
appointment with you for 6 months. I would figure, hey, maybe 
we better hire another practitioner, and we did. And that is 
what I see there.
    So my time has expired, Mr. Chairman. Thank you for 
indulging me.
    Dr. Benishek. Thank you, Mr. Roe.
    Mr. O'Rourke. You are recognized for 5 minutes.
    Mr. O'Rourke. Thank you, Mr. Chairman.
    I want to thank everyone on the panel for being here. And 
your commitment to improving the VA and serving our veterans 
gives me an opportunity to remember and thank those who serve 
the veterans in El Paso, Texas. That is the district I have the 
honor of serving.
    And, Dr. Salvo, your story of continuing to treat veterans 
without compensation reminds me of people that I have met at 
the VA who are providers there who could be working in the 
private sector at much greater pay and probably much less 
frustration and yet choose to work at the VA because they want 
to serve veterans, and they do a wonderful job.
    And I hear that from the veterans that they treat and serve 
directly, you know, that it is really hard to get in, and there 
is a lot of frustration with the bureaucracy, but once you are 
seen by a provider, typically, the experience is excellent. And 
I think that is something that I have heard my colleagues on 
the committee share, as well.
    Two things stick out to me, in terms of the larger picture. 
One is--we heard the Deputy Secretary say this day before 
yesterday, Sloan Gibson--that there are 28,000 unfilled 
positions at the VA today. Just the hiring challenge there is 
just monumental, staggering. I don't know how you get over it. 
And it hasn't improved in a year.
    And the other is that wait times also have not improved in 
a year. You know, $15 billion or $16 billion authorized and 
appropriated this summer; program went live in November. Dr. 
Spagnolo, you said you are not sure if you have seen any 
significant change in access or treatment as a result of that. 
We know from a hearing earlier this week that we thought that 
$10 billion of that were going to be obligated sometime in the 
early part of fiscal year 2016, which could take you to maybe 
December or January, you know, in the next 6 months, and only 
$500 million has been obligated.
    So you all have each offered important suggestions to 
improve the delivery of care and the hiring and the speed at 
which we bring people on board. And I am really glad that Dr. 
Lynch is here to listen to all this, and I know that he is 
taking note of this and will incorporate these, I hope, into 
the operations at the VA. But I am also looking for some kind 
of big breakthrough in what we are doing.
    I don't know that, with these 28,000 outstanding hires, 
with wait times that haven't improved despite the notoriety 
around the crisis in Phoenix and all the attention that we have 
spent and the new legislation that we thought was going to fix 
it, I don't know that this model works, nor should we expect it 
to work.
    And, you know, one of you said it is not going to be a 
matter of resources. We can't throw more money at this and just 
expect it--we can hire people more quickly. You know, I heard 
these same stories. We had a psychologist who was hired from 
Georgia, recruited by the VA in El Paso. And he said, you know, 
sure, I would like to do this job, sign me up, and it took 3 
months to bring him on. They recruited him, and it took 3 
months. And in that time he said, you know, there were several 
other offers, and I thought about taking them, but I wanted to 
serve in an underserved area.
    So I realize I have chewed up most of the time I had, but I 
want to offer the last minute and a half to anyone who might 
have a big breakthrough idea on how we change what is obviously 
a system that just doesn't work.
    Ms. Clifford, it looks like you might have one.
    Ms. Clifford. Well, I don't know if it is a breakthrough 
idea, but if we don't address the human resource piece of it--
and from that, I just want to go on record as saying it is not 
the staff that are doing the work there. They are killing 
themselves trying to help us get these people in. But the task 
ahead of them is just so overwhelming that--I don't know what 
their retention rates are, but I would think they are not very 
good because they turn over very quickly. Because it takes a 
lot of time to get them trained, and so they don't stay long 
enough to get trained. And they go to other jobs, either in 
other parts of the government or out of human resources 
altogether.
    So if we kind of don't address that area--because they are 
our bread and butter of getting people in.
    Mr. O'Rourke. And that is an open question from me to each 
of you. And I am sure my colleagues on the committee would all 
be interested in hearing your answer. So we are not going to 
have time to get that from each of you today, but know that I 
think, you know, speak for myself, very interested in a 
different way forward.
    I think more of the same we have seen from the last year, 
despite, you know, what I think is tremendous leadership on the 
part of the VA and the new Secretary, it is just not working. 
And the people who are delivering that care on the front lines 
are suffering, and what is even more important, the people that 
they serve are suffering. And we have to have a big, bold path 
forward to fix this.
    So, with that, I yield back to the chair.
    Dr. Benishek. Thank you, Mr. O'Rourke.
    Mr. Coffman, you are recognized for 5 minutes.
    Mr. Coffman. Thank you, Mr. Chairman.
    We get scope-of-practice questions here in the Congress 
relative to the Veterans Administration. I think a lot of these 
issues have been resolved down at the State level before State 
legislatures. And I have been on both sides of it as a State 
legislator, where I think they are better qualified at the 
State level to make those decisions. They can have hearings; 
you know, they know that the docs, the providers within their 
communities.
    And so I guess my question to you is, clearly, you know, 
people that--well, my question to you is, what do you think 
about devolving the scope-of-practice issues down to reflect 
whatever the standards are within the given States that these 
VA facilities are in, number one?
    And, obviously, we are going to make sure that the 
providers are properly credentialed or trained to be able to 
perform those duties within the scope of practice. So devolve 
it down to the State level, reflect State regulations wherever 
these VA facilities are, as opposed to us relitigating these 
issues at the Federal level.
    Would anybody like to comment on that?
    Ms. Clifford. Well, I can speak to it from the advanced 
practice realm. And the issue becomes--we care for patients 
across States, and so different States have different nurse 
practice acts which allow the nurse practitioners to do 
different things at different levels and how much independent 
practice they can have.
    So, in VA Boston, for example, we are a referral center, so 
we are patients from Maine and New Hampshire, and yet the nurse 
practitioners in some States are able to do things and are not 
able to in other States. So it makes it--it is hard for us to 
give equitable care across all of our veterans when we have 
different practices across.
    Mr. Coffman. Anybody else?
    Dr. Spagnolo. I am not sure I could respond to that because 
I have never really thought of that as an answer, but probably 
have to probably look at that a little bit more and see where 
that would take us. But it may be a possibility; I don't know. 
But I would like to get back to you on that.
    Mr. Coffman. As an example, the issue between 
anesthesiologists and nurse anesthetists has been settled 
across this country in different States. And now both sides 
want us to relitigate it here at the Federal level where I 
would just as soon to defer to those State legislatures who 
have made those decisions. So that would be an example.
    Dr. Spagnolo. I would have to look at that across State 
lines. I don't have a good answer for you on that whole issue. 
But I will get back to you on that.
    Mr. Coffman. Okay.
    Thank you, Mr. Chairman. I yield back.
    Dr. Benishek. Thank you, Mr. Coffman.
    Mr. Takano is next.
    Mr. Takano. Thank you, Mr. Chairman. Thank you.
    Ms. Clifford, thank you for your testimony today about the 
vital that role nurses play in the VA and how we can better 
attract and retain nurses to care for our veterans.
    You mentioned something about streamlining the hiring 
process and improving education resources for nurses, but I am 
wondering about your thoughts about giving nurses improved 
rights to raise grievances about staffing levels and how that 
can improve the workplace, empower nurses, and encourage them 
to continue serving our veterans.
    In a statement submitted for the record, the AFGE mentions 
that through a loophole nurses and other VA healthcare 
providers are denied full collective bargaining rights that 
other Federal employees have. The AFGE supports a bill that I 
have introduced, H.R. 2193, the VA Employee Fairness Act, to 
expand providers' ability to negotiate to improve staffing 
levels and in turn the care our veterans receive.
    Mr. Takano. Do you think we need to pay attention to the 
work environment to attract and retain skilled nurses?
    Ms. Clifford. Yes, sir. And in VA nursing we actually use 
an expert panel for staffing methodology model, in which case 
we use front-line staff to participate in what those staffing 
levels and numbers should be for those individual units. That 
is the model that we use. So we do involve front-line staff in 
that, and they look at the demographics of their unit, the 
turbulence of their unit, the things that are going on in their 
unit, and the acuity levels to determine what should be the 
appropriate staffing mix and level. And those recommendations 
are then put forward through the nurse executive to the 
resource committees at those.
    Mr. Takano. Dr. Spagnolo, the similar question regarding 
the ability to collectively bargain, to set staffing levels. Do 
you think that expanding the collective bargaining rights and 
physicians' ability to negotiate would play a role in ensuring 
physicians' voices are heard, you are paid attention to by the 
folks that are making decisions?
    Dr. Spagnolo. Frankly, I am not sure I have an answer to 
that question. We currently have union representation in the 
hospital that gets involved in a lot. I think some of these 
issues, it seems to me many times it makes it more complicated. 
I think if we could empower more people within the hospital we 
could probably eliminate a lot of these problems that have to 
do with working conditions.
    Mr. Takano. How do you empower them without having 
collective organization? How are you going to be heard and 
listened to? How are you going to get people to listen to you 
unless there is some leverage?
    Dr. Spagnolo. Well, I am not quite sure I understand that 
question. But if you are talking about pay or are you talking 
about working conditions?
    Mr. Takano. Well, working conditions are also part of what 
are collectively bargained.
    Dr. Spagnolo. I am not sure, the issues that we have been 
discussing here, I don't know if you need that kind of 
collective bargaining agreement. I think if we can all sit down 
around the table, we could solve these problems.
    Mr. Takano. Okay. Thank you.
    Mr. Spagnolo, I want to briefly ask you this question. 
Isn't there a tremendous physician shortage in the country? 
Does that not play into why it might be difficult for the VA to 
recruit physicians?
    Dr. Spagnolo. There is a physician shortage in some areas, 
I agree with you on that.
    Mr. Takano. Primary care?
    Dr. Spagnolo. I think in primary care. But, again, I keep 
coming back to the same issue, it is a revolving door, if you 
don't make things a little better. I think the salaries in the 
last 10 years have come up significantly.
    Mr. Takano. Okay. On the physician's assistant side, I am 
just wondering about whether or not there might be some 
education inflation. I was interested to hear that the military 
was the beginning of the whole idea of PAs. There are community 
college programs that will take, up until now, PA people who 
had up to 5 years of experience, say, in the military, and with 
a community college program of 2 years they can become PAs, but 
I understand that the accreditation has moved had a to a 
master's degree minimum.
    Ms. DaSilva. Yes, sir.
    Mr. Takano. Is that something you agree with, Ms. DaSilva?
    Ms. DaSilva. I went to a community college and applied to 
an accredited physician assistant program. So it is at a 
master's level now. The Grow Your Own, the ICT is a great 
program and a great pathway to let returning corpsmen and 
medics coming back who are OIF/OEF to have a pathway to go and 
become physician assistants. So, yes, it is a master's program 
now and it has to be accredited.
    Mr. Takano. But is the loss of that pathway through the 
community college to your program, is that a problem? I mean, 
is that kind of added burden necessary?
    Ms. DaSilva. Sir, when I applied to PA school, and to my 
knowledge there is not a pathway that you can go to a community 
college and become a physician assistant, it at a minimum was a 
bachelor's program even when I applied in 1999. I did not know 
of any community college that was offering the physician 
assistant program at that time. There were very few even at 
that time that were offering a bachelor's, they had all turned 
to a master's program and now even offering doctorate's.
    Mr. Takano. Thank you. I yield my time back.
    Dr. Benishek. Thank you.
    Dr. Wenstrup.
    Dr. Wenstrup. Thank you, Mr. Chairman. And I want to thank 
you and the ranking member for putting this panel together and 
for all of you being here today. I think it is very insightful 
and it provides us with a lot of opportunity to make things 
better in the VA by hearing what you have to say today.
    When I first got here 2 years ago, and this is before 
Phoenix broke and everything else, coming from private practice 
I was concerned, I remember asking Dr. Petzel if anybody on the 
administrative staff have ever been in private practice where 
they had to be in the black to keep their doors open and none 
of them had. And I found that very significant and a key part, 
especially when you talk about physician directors today being 
involved. It would be even more helpful if they had some 
private practice experience and prove efficiency.
    I also asked the question at the time, I said: Do you think 
the VA, if you took all their expenditures like a private 
practice has to do, their physical plant, their nurses, their 
assistants, their supplies, their insurance, and all the bills 
that they had to pay, I said if the VA looked at themselves 
that way and took fee-for-service at Medicare rates, would you 
be in the black. And he said yes. And I about fell out of my 
chair, because I know how tough it is to be in the black seeing 
three times as many patients as the VA was doing.
    And I greatly appreciate what you are talking about today, 
where you have physicians doing things that in a private 
practice you have someone else do, so that you can care for 
more people. And that really is the bottom line. So I really 
appreciate what you are saying today.
    Look, on this committee alone we have five physicians. If 
we can't make things better sitting here, then we are in 
trouble. This is an opportunity that should not be wasted, and 
I hope that we proceed in that direction. So thank you all for 
advocating on the things that I think we all believe in.
    I do have one question, and it has to do with retention and 
recruitment and the length of time it takes to fill a spot. I 
think we have touched on some of the reasons why it is tough, 
but I am curious how long it takes to fill a spot. Because I 
have had young doctors, podiatrists, M.D.s, come to me and say: 
I looked into it, but I didn't see a bright future here. And 
especially when you talked about the podiatry pay issue.
    So if you could both weigh in on length of time it takes to 
actually fill a slot on average and the challenges, I would 
appreciate it.
    Dr. Spagnolo. I don't know what else to tell you other than 
the processes are so complicated and it has got to go through 
so many levels and then it has to get approved and reapproved 
and on a resource committee meeting and then off of committee, 
and sometimes the committee doesn't meet for 2 months, and then 
it goes to HR, and then back to the resource committee. That 
just takes forever.
    Dr. Wenstrup. Well, that is what I want to hear. And I am 
hoping working with you we can come up with a plan that 
streamlines that and makes it a whole lot more efficient.
    Dr. Spagnolo. I would be delighted to help you work on that 
plan.
    Mr. Chairman, I have a clinic at 1 o'clock, which we have 
40 people waiting on me. May I be excused?
    Dr. Benishek. Yes, I suppose so.
    Dr. Wenstrup. Well, Dr. Salvo, I would like you to weigh in 
as well, if you can.
    Dr. Salvo. Thank you. I am in complete agreement with Dr. 
Spagnolo, and he indicated earlier in his testimony an 
approximate wait time in terms of getting credentialed and 
privileged and starting in the VA approximately 1 year. And if 
I were to consider the average, that is probably true.
    When I left my post in the Cleveland system, it was 14 
months before that was filled. I have had two WOC (Without 
Compensation) positions since have I started my current 
position with APMA. One took me 11 months. The other one, 
surprisingly, took me 5. It is an excessive, burdensome process 
when you factor in VetPro and you factor in the application 
process along with all of the forms and the various HR levels 
and committees that everything has to be completed. So it is 
extremely, excessively burdensome.
    Dr. Wenstrup. Thank you very much for your testimony.
    I yield back.
    Dr. Benishek. Thank you, Doctor.
    Ms. Kuster.
    Ms. Kuster. Thank you very much to our chair and the vice 
chair for holding this hearing.
    And I apologize to all of you that we have flights that we 
have to catch, but I appreciate you being here and look forward 
perhaps another time that we could bring Dr. Lynch back so that 
more of us could hear.
    I just want to focus in. I had the opportunity just 
recently to visit the White River Junction, Vermont, hospital, 
which is the VA hospital that serves many of the folks in my 
district. And I think they are very focused on veteran-centric 
care. They have actually had some very good results from the 
Choice Act in hiring just recently. In fact, they were focused 
on getting nurse practitioners into our CBOC so that in the 
rural communities they would have the prescribing ability to 
stay on top of medications and prescribe without people having 
to go down to the VA hospital.
    But I want to focus in on the question of the PAs, and just 
generally I am pretty familiar with the private sector and the 
fact that this is a national trend, we are pushing down our 
medical care to the right person, at the right time, for the 
right task. So it doesn't surprise me that somebody would come 
in and not see a physician. I don't typically see a physician 
when I get care in the private sector. If I can see a PA or see 
a nurse practitioner, I get terrific care. So I don't want to 
mislead anyone about what is expected.
    My concern about the PAs is this chronic loss rate, 12 to 
14 percent loss rate, and particularly comparing it to a very 
favorable practice with the nurse practitioners in their 
residency program, 100 percent retention of employed nurses 
after 1-year of employment, as compared to over a loss rate of 
over 10 percent in other practices.
    I am wondering, and this is for Ms. DaSilva, have you see 
anywhere, whether it is in the VA or outside, it could be a 
best practice that we could bring in, a residency-type program 
where we could be more focused on our PAs, give them the 
support that they need to be able to stay on the job, because 
my understanding is it takes at least 6 months to replace a PA. 
That is expensive. It is expensive to the system. And, as I 
say, I am just focused on veteran-centric care. Can we get them 
the care that they need?
    Ms. DaSilva. Thank you for that great question.
    The issue when you were talking about the residency 
program, we don't have a particular, like, Grow Your Own 
residency program. When I had given my verbal testimony, I 
talked about the scholarships that are just not available. So 
if you have a medical technician or somebody in the VA system 
who says they want to go on and become a physician assistant, 
there aren't really funds that are nationally set aside for it. 
It is up to each local facility if they do that. There isn't a 
definite program that you can apply to and have a pathway to 
become a physician assistant.
    So if you wanted to do that, you would have to take out 
loans or leave the VA system or come into the VA system, spend 
a short amount of time, and then leave. That is why we were 
talking about the Grow Your Own. So if you do have corpsmen 
medics who are in the VA system or returning, can come and work 
at the VA, get their PA school paid for, and then continue to 
work within the system.
    That would be the ideal pathway to do and to set aside. 
There are education debt-reduction programs to have PAs come 
and work in the system. However, the funding is at a local 
level, so it is not nationally mandated. So if you ask at the 
local level, they may say that the funds are not available.
    Ms. Kuster. So I would be very interested in looking into 
bipartisan legislation to bring the PAs in line with both the 
debt reduction and the scholarship programming too. And I love 
the idea of our returning vets. I know we have talked a lot on 
this committee about aligning their abilities and making sure 
that they have a path to successful employment in the private 
sector.
    And then just briefly, my time is almost up, but I did want 
to just mention I am also interested in the mandated surveys, 
to include our PAs in the mandated salary surveys in the 
community so that we better align the compensation for PAs. But 
I think we should do what we can to make sure that doctors are 
working at their highest and best use and that they have the 
support to see more patients. I am a big fan of bringing in 
nurse practitioners and nurses obviously for what they can do 
for it. And I really want to be supportive of getting PAs up to 
speed and well compensated so that they will be able to 
participate as well.
    So thank you very much.
    And I yield back. Thank you.
    Dr. Benishek. Thank you, Ms. Kuster.
    Dr. Abraham, you are recognized.
    Dr. Abraham. I first want to give Dr. Spagnolo who has left 
accolades for having the patience of Job, if he is able to work 
40 years in the system that requires him to enter data. I know 
as a practicing physician when my triage nurse would call in, 
or my scribe when we used the electronic health records would 
call in sick, I would see two-thirds, if not 75 percent less 
patients that day when I actually had to do the work. So the 
hard work is actually done by those nurses and good triage 
people that make us look better than we probably really are.
    Saying that, I have worked also with PAs and NPs all my 
career, and the service and the level of care that you provide 
is outstanding.
    Dr. Salvo, on the podiatry front, I have referred patients 
all my career to podiatrists for anything from Charcot foot to 
diabetic cultures, and again could not ask for a better level 
of care from your profession. So kudos to you guys.
    I find it odd that in programs such as Choice or anything 
that is non-VA related that the VA doesn't mind that our good 
veterans are being seen outside the VA clinic by board 
certification other than ABMS. They allow the AOA, I think that 
is the osteopathic board, and the ABPS, the profession that you 
represent, Mr. Morris, they allow them to see them and don't 
seem to have a problem with that, but they evidently have a 
problem hiring those same types of board certifications in the 
VA hospitals themselves.
    Again, going back to my little world of a practicing 
physician before this job, I used physicians of every specialty 
certification, for hospitalists, for referral. And across the 
board there was no difference in care. They all, whether it be 
the ABMS, your profession that you represent, the AOA, all 
provided, again, outstanding level of care, either outpatient 
or in the hospital, for my patients.
    So I guess the question is, how many physicians do you 
think have been denied positions at the VA because of their 
different board certification?
    Mr. Morris. We couldn't get an accurate--I mean, there is a 
lot of our membership, which is why we have been pushing this 
issue. Most of them are even veterans themselves. We have tried 
to reach out to get those counts, to get those numbers, but 
unfortunately in the politics of medicine some of the 
physicians are even afraid to even come forward to say things 
because there are blacklists or names that get out to where if 
they do get an opportunity to get a job, they have been denied 
these instances.
    The politics of medicine regarding board certification has 
been something that I was shocked to see when I first came in. 
If you are having great physicians denied opportunities or even 
great physicians working within the VA system denied levels of 
promotion, denied movement along in their career solely because 
they chose the smaller board. And we are here today and we have 
been here continuously having you meet our physicians to really 
show them that it should be looked at the physician as a whole 
of their education, training, and experience, not what choice 
they made in their board certification.
    Dr. Abraham. Thank you.
    Mr. Chairman, I yield back.
    Dr. Benishek. Thank you.
    Well, I think everyone has had an opportunity. So if there 
are any further questions, otherwise we will excuse the panel.
    Well, you all are excused then. Thank you very much for 
your testimony. We really appreciate you coming in here.
    Dr. Benishek. I will now welcome our second panel to the 
witness table. Joining us in the second panel is Dr. Thomas 
Lynch, the VA Assistant Deputy Under Secretary for Health for 
Clinical Operations. Dr. Lynch is accompanied by Elias 
Hernandez, the Deputy Chief Officer for Workforce Management 
and Consulting, and Dr. Gage, the Chief Officer of Nursing.
    Thank you all for being here.
    Once you get settled, Dr. Lynch, you are welcome to begin 
your testimony.

    STATEMENT OF THOMAS LYNCH, M.D., ASSISTANT DEPUTY UNDER 
 SECRETARY FOR HEALTH FOR CLINICAL OPERATIONS, VETERANS HEALTH 
     ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS, 
   ACCOMPANIED BY ELIAS HERNANDEZ, DEPUTY CHIEF OFFICER FOR 
     WORKFORCE MANAGEMENT AND CONSULTING, VETERANS HEALTH 
ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS, AND DONNA 
  GAGE, PH.D., RN, NE-BC, CHIEF OFFICER OF NURSING, VETERANS 
   HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS

             OPENING STATEMENT OF THOMAS LYNCH M.D.

    Dr. Lynch. Thank you, Mr. Chairman. I think I got the short 
chair here, but I will try to make the best of it.
    I would like to go off script for just a minute after 
acknowledging you, Mr. Chairman, Ranking Member Brownley, and 
the members, and thanking you for the opportunity to discuss 
VA's ability to recruit onboard and retain qualified medical 
professionals.
    I want to acknowledge the panel that preceded us. I want to 
acknowledge the opportunities that they afforded us I want to 
hear. I wanted to echo Secretary McDonald's statement of the 
other day that we really need to engage and empower our 
employees. We need to listen and we need to learn because they 
will help us provide better care to veterans.
    With that said, I would also like to acknowledge today that 
I am accompanied by Mr. Elias Hernandez, Dr. Donna Gage. Mr. 
Hernandez was recently appointed Chief Officer for VHA's Office 
of Workforce Management and Consulting and is responsible for 
providing human resource support services and training. Dr. 
Gage, who recently joined VA from the private sector, serves as 
VHA's Chief Nursing Officer and advises on all matters related 
to nursing and the delivery the patient care services.
    Establishing and realizing staffing requirements for VA's 
healthcare system is a very complex task. The VA operates over 
1,000 points of care across the country and provides a full 
range of primary and specialty care services for patients 
ranging in age from our youngest, recently discharged 
servicemembers to our most senior veterans. Rural populations, 
unique health conditions resulting from combat experiences, and 
an increasing number of women veterans require a commensurate 
array of professionals to address their unique and individual 
requirements.
    Adding to the challenge is the fact that there are many 
approaches to medical professional and support staff modeling 
across large healthcare systems. There is no one-size-fits-all 
model and no single set of staffing management tools from the 
private sector or elsewhere that we can borrow. These are 
indeed challenges, but they are no means an insurmountable 
barrier to achieving the goal of timely access to care for 
veterans.
    VA is leveraging our national recruitment program, 
dedicated recruiters partnering with facilities and identifying 
hard-to-fill positions, marketing, and hiring qualified medical 
professionals. We are promoting scholarships and loan repayment 
programs, such as the Education Debt Reduction Program and 
employee incentive scholarship programs, as expanded by VACA. 
We have increased the physician and dentist compensation pay 
tables in order to attract and retain qualified healthcare 
providers. We are improving the credentialing process for VA 
and DoD healthcare providers, which involves sharing 
credentials to speed up the process.
    In the last 12 months, VA has hired more than 37,000 new 
employees, with a net increase of over 11,000 medical 
professionals and staff. This includes about 1,000 physicians 
and 3,000 nurses.
    In addition, we are leveraging new technology to expand the 
reach of healthcare providers. From 2010 to 2014, there was a 
114 percent increase in the use of all healthcare technology 
among unique veterans. At the end of 2014, 12.7 percent of all 
veterans enrolled in VA care received telehealth-based care. 
This includes over 2 million telehealth visits, touching 
700,000 veterans.
    To address the increase in the rural veteran population, 
the VA's Office of Academic Affiliations, in partnership with 
the Office of Rural Health, is sponsoring a 3-year Rural Health 
Training Initiative. The project is designed to fulfill VA's 
mission to serve veterans living in rural areas. Funding under 
this request allows VA facilities to expand health professions 
training to rural VA locations. Additional trainee positions 
awarded as part of this initiative become part of each 
facility's permanent base location.
    As you can see, we have made significant progress, but we 
realize we still face many challenges with wait times, the 
provision of rural healthcare, and the commitment to women's 
health issues. By increasing staff, clinical space, community 
care, and the hours of care available we believe our recent 
progress has resulted in some increases in the number of unique 
patient visits and large increases in the number of 
appointments for veterans already enrolled. We have completed 
2.5 million more appointments inside VA this past year.
    We also believe that in many specific locations, with the 
longest wait times, the more access we offer, the more veterans 
will seek VHA care services. It is also a challenge to recruit 
healthcare professionals at some of these locations. These are 
all contributing factors as to why wait times are stagnant in 
some areas and why we must focus our efforts.
    In conclusion, Mr. Chairman, we have the best clients in 
the field of healthcare. We are grateful for Congress' support, 
and we look forward to your continued assistance in getting the 
best doctors and nurses to serve veterans. The challenges 
remain formidable, but our commitment to timely, accessible 
care and a positive patient experience is unwavering.
    Mr. Chairman, this concludes my opening remarks. My 
colleagues and I are prepared to answer any questions you and 
the members of the committee may have.

    [The prepared statement of Dr. Lynch appears in the 
Appendix]

    Dr. Benishek. Thank you, Dr. Lynch. And I will yield myself 
5 minutes for questions.
    It is great that you come and you tell us how well you are 
doing and how much improved and you cite these statistics and 
stuff, but it is really frustrating to me. You heard the 
testimony from the previous panel and that there seems to be 
just way too many orders from above about how things get done 
within the VA and that there is not enough, what Dr. Spagnolo 
talked about, is that the people on the ground who are actually 
taking care of the patients get to make some decisions that 
affect how the process works.
    Now, the VA provides hospitals, and this bureaucratic mess 
does not occur at the same level in private hospitals. So not 
every single private hospital has 2,000 clinics, but they seem 
to do a better job of hiring and firing and having processes 
work efficiently than the VA. And I think a lot of it is 
because the people on the ground have more power to actually 
change things.
    Now, I will give you a great example of this, is I just 
went to a CBOC in my district, and one of the complaints that I 
had was that everybody who went and saw the patient had to sign 
in and out on the computer. There was a computer in the examine 
room, the nurse goes in, she has to sign into the computer, she 
has to sign out when she is done. The doctor comes in, he has 
got to sign in and sign out to write anything down about the 
patient. They can't take their laptop with them and stay signed 
in. They have to wait 5 minutes signing in every time they see 
a different patient. And it was like the cumulative time of 
signing in and signing out of the computer was, a huge waste.
    So the people in the clinic are telling me that this is a 
big time killer in their clinic and yet nobody could get that 
changed, because the way they were doing it was from above. 
Those are the kind of processes, Dr. Lynch, that need to be 
solved at the local level because every single little clinic or 
hospital is going to have an issue like that that has to be 
done.
    And I have been here for years now listening to what you 
guys have been doing as far as physician staffing, for example, 
eight times in the last 30 years the inspector general has told 
the VA that they need a central plan for hiring physicians and 
eight times the VA has agreed with the inspector general that 
they need that. But they haven't gotten a central plan for 
hiring physicians over the last 30 years.
    So what has changed, Dr. Lynch? How can we get this moving? 
How can we jump-start this? I mean, it is the same answers I 
hear. It is not working.
    Dr. Lynch. So let me start by agreeing with you on one 
point. I think the aggravation of dealing with our computer 
system is exceedingly frustrating. I think the other side of 
that, fortunately, is that it provides a very accurate medical 
record.
    I would disagree in that I think the solution is probably 
central and we need to look for ways to make computer access 
more efficient across our system. I don't think it is a local 
problem. I think it is larger.
    Dr. Benishek. Well, I could tell you that at the hospital I 
worked at I had a laptop of my own that I used. I signed in 
once, I kept it with me, and I went and saw a bunch of 
different patients. I didn't have to sign in and sign out. That 
was not a centrally planned decision, that was a locally 
planned decision, and it was a lot better for everybody. The 
nurse had her computer at the nursing station. She just went 
back and forth and didn't have to sign in and sign out, lose 
your spot, all that baloney.
    And somehow you can't solve that simple problem? But your 
answer is it has to be solved centrally. That is the wrong 
answer, Dr. Lynch. That is what I am trying to tell you.
    Dr. Lynch. I understand your position, but I am going to 
disagree. And we end up facing obstacles from Homeland 
Security, and the risk of access to national computers limits--
--
    Dr. Benishek. Everybody has a problem with the security of 
health computers, so don't tell me it is special to you, okay, 
because everybody is concerned about the patients' privacy on 
healthcare. So these are answers that don't make any sense, Dr. 
Lynch, and I am very disappointed to hear this kind of stuff. I 
want your solution to these problems, and I think it goes down 
to not having enough control locally.
    Mr. Hernandez, let me ask you a quick question before I am 
out of time about Ms. Clifford's HR question and statement that 
it is so unwieldy. What can you do about? Quick.
    Mr. Hernandez. Thank you, Mr. Chairman.
    I will tell you, Mr. Chairman, and to acknowledge to the 
subcommittee that we do have a complex HR system which is 
comprised of two different personnel----
    Dr. Benishek. What have you done in the last year to change 
that?
    Mr. Hernandez. We have trained the HR professionals, the 
credentialers, the leaders of the organization, and the hiring 
managers at the local level to understand the hiring process 
and the roles and responsibilities during that process.
    Dr. Benishek. Have they changed that process in the last 
year to make it simpler?
    Mr. Hernandez. Sir, we are looking. Mr. Sherman----
    Dr. Benishek. You have not then, that is a no, you have not 
changed the process in the last year to make it simpler.
    Mr. Hernandez. We have, Mr. Chairman.
    Dr. Benishek. What have you done?
    Mr. Hernandez. We have visited the----
    Dr. Benishek. What have you changed in the process of 
hiring people in the last year that made it simpler, one thing?
    Mr. Hernandez. We have educated the H.R. community----
    Dr. Benishek. No, no, no, not educate the person. What 
about the process have you changed in the last year to make the 
hiring easier?
    Mr. Hernandez. That is what I am trying to convey, Mr. 
Chairman, that the hiring authority that we have given to us by 
Choice, as well as the flexibilities that we have of hiring 
Title 38 and Title 38 hybrid occupation is being fully utilized 
systemwide.
    Dr. Benishek. Okay. I am out of time. I am sorry.
    Ms. Brownley. Thank you, Mr. Chairman.
    Well just to follow up on that line of questioning, I think 
Mr. O'Rourke asked the first panel, what is a big, major thing? 
That is what he was looking for, something big and a big 
change. And Ms. Clifford answered by saying it is human 
resources. And I think, and I think this is what the chairman 
was getting after as well, is that there are so many rules that 
you have to follow that that really slows the process down.
    So to me it is the rules, and we probably need more human 
beings and human resources to carry out the task and the 
mission of the amount of people that we need to hire within the 
VA, which many would say is insurmountable. It is a huge number 
that we need to hire.
    So can you address, is there anything underway to evaluate 
rules that might have been made two decades ago that can be 
changed, rules that can be changed, and what we can do to hire 
more in human resources to get this engine running at a higher 
speed to hire new professionals within the organization?
    Mr. Hernandez. Yes. Ranking Member Brownley, there have 
been numerous engagements at the local level by subject matter 
experts from the national level to provide support in terms of 
the processes that we currently have.
    And I would like to state this, because it is very 
important, and perhaps it may look like a simple issue. But we 
have integrated the requirements identification at the local 
level with the responsibilities of the human resources 
professionals, as well as the hiring managers, the people that 
are responsible for space and equipment, and the individuals 
responsible for the credentialing process. Where at one time 
those processes used to be independent and used to operate in 
silos, we have integrated those particular processes so we 
don't have the delays that the other panel mentioned to the 
subcommittee earlier. And we have proven that in Phoenix, we 
have proven that, the process has worked in St. Louis.
    Ms. Brownley. Okay, so you have gotten rid of silos and 
there is a more integrated process, where in certain areas in 
the country we are speeding up the process. Have you had any 
directive from above to say we need to really review the rules 
within human resources and adding additional personnel? And is 
anything like that underway?
    Mr. Hernandez. Yes, ma'am. I will tell you that last year 
the Leading Access and Scheduling Initiative looked at the 
processes and the barriers that we had in the local level in 
terms of HR and as well as the national level, and we were able 
to change a lot of the VHA policies that were identified as 
barriers.
    In terms of the human resources situation that we currently 
have, we are looking at that particular process in terms of 
bringing up that particular issue to the national level 
committee so that we can address that particular situation.
    Ms. Brownley. But have you had a specific directive to hire 
additional people and continue to make changes within the rural 
process to streamline the whole hiring process? You have had 
directives?
    Mr. Hernandez. We have had guidance issued to the field, 
yes, ma'am.
    Ms. Brownley. So, Dr. Lynch, in terms of the testimony from 
the American Podiatry Association, is there something that we 
need to do legislatively to fix what they testified in? And if 
there is not a need for a legislative fix, is there something 
the Department can do to recognize their growing mission? And I 
think they also testified vis-`-vis their salaries, et cetera. 
So how do we get more podiatrists within the VA? Do we need to 
fix that legislatively or can that by fixed internally?
    Dr. Lynch. So let me first acknowledge the work that 
podiatrists do. As a vascular surgeon, I have worked closely 
with podiatrists throughout my career and I appreciate the 
value of their product.
    There have been several suggestions that have been 
provided. One was suggested this morning that VA be given the 
authority to recognize podiatrists as physicians, as CMS does. 
Other changes are to our handbooks. But it appears that one of 
the more significant opportunities may be legislation, and we 
are more than happy to work with the committee to provide the 
clinical input to the development of any legislation that may 
bring that forward.
    Ms. Brownley. Thank you. I will yield back.
    Dr. Benishek. Dr. Wenstrup.
    Dr. Wenstrup. Thank you, Mr. Chairman.
    Dr. Lynch, you said something that really struck, and it is 
not on you, but what you said is there are homeland security 
issues. And I think what a shame it is that the veteran going 
to the doctor becomes a homeland security issue. And that tells 
me that we have become way too connected in everything that we 
do with the core of the Federal Government that when you go to 
the doctor you have to have these issues.
    Because I can tell you from many years in my practice, may 
be changed since we have had to use EMR forced on us by the 
government and connect with all these people and people's 
medical records are now going everywhere rather than staying 
within your office, but I can tell you, for years any 
individual, veteran or otherwise, that came to me for care 
wasn't worried about Russia, China, North Korea, or Iran.
    We need to have a solution to that problem, and you are in 
the middle of it, and I would love to hear some solutions, 
because that should not be a concern of veteran, that it is a 
homeland security issue for them to go to the doctor.
    Dr. Lynch. Congressman, I don't disagree with you, and I am 
as frustrated as you are.
    Dr. Wenstrup. I am sure you are.
    Dr. Lynch. And I have lived it, okay, and I don't know what 
the solutions are, but I agree entirely that we need to figure 
out a way that we can streamline the medical care system that 
now has the opportunity to use virtual technologies and not let 
it get tied up in security issues that actually create more 
work rather than less work.
    Dr. Wenstrup. But I agree with Dr. Benishek, and it is the 
same on DoD side from personal experience. You are putting your 
CAC card in a million times a day rather than seeing patients 
and you are going back and forth. I mean, the difference, in my 
practice if somebody comes, they tell a medical assistant there 
is someone up front, what is wrong with them, how they injured 
themselves. They turned their ankle, we go get an x-ray. 
Haven't seen the doctor yet. Now they see the doctor, the x-ray 
is there. I hadn't had to plug in three times to make that 
happen and do that from patient to patient.
    Let us help you help fix this problem by coming up with 
solutions that we can insist that the VA make changes. And I 
know as a practicing physician, if you have had to experience 
that or know the difference, help us come up with the solutions 
and demand that we get it done.
    Dr. Lynch. Yes, sir.
    Dr. Wenstrup. Thank you. I yield back.
    Mr. Takano. Thank you, Mr. Chairman.
    Dr. Lynch, in your testimony you mentioned that as a result 
of the Choice Act the VA has already hired 2,500 medical 
professionals and support staff. Did I get that right?
    Dr. Lynch. Twenty-six hundred actually, yes.
    Mr. Takano. Twenty-six hundred. Were all of those new 
positions or were some of those staff hired to fill existing 
vacancies?
    Dr. Lynch. To my knowledge those were new positions.
    Mr. Hernandez. New positions.
    Dr. Lynch. New positions.
    Mr. Takano. Okay. Well, with the resources the Choice Act 
provided will the VA be able to shorten the long wait time it 
takes to fill the vacancies at the VA?
    Dr. Lynch. I am confident they are. I think Mr. Hernandez 
implied earlier that human resources has begun looking at their 
process. It has in the past been a serial process. It needs to 
be a parallel process. It can be complex, but it can be 
simplified. It requires proactively assessing our needs. In 
certain cases it requires staffing to organizational charts. We 
know somebody is going to leave, we know that position is 
approved, let's replace it. It involves communication, it 
involves preparation.
    I think, to the chairman's point, this is where the 
clinical staff does need to get involved with the leadership 
and with human resources to further the efficiency of the 
process that we currently have. It is not efficient, it takes 
too long. I think we know how to change it. I think we have 
begun to implement changes. We need to go further.
    Mr. Takano. Another vital provision of the Choice Act was 
the increase of 1,500 GME slots. I understand that the first 
round of residencies have already been awarded.
    Dr. Lynch. Yes, sir.
    Mr. Takano. And that the VA is moving forward with the 
second round.
    Dr. Lynch. Yes, sir.
    Mr. Takano. Will expanding the number of residencies 
improve the pool of candidates for the vacancies at the VA?
    Dr. Lynch. Absolutely. Two standpoints. Number one, I think 
VA has a unique advantage over the private sector. Currently, 
we have over 40,000 residents and medical students that rotate 
through our VA. We have nurses as well. These are all potential 
employees. We have first chance at evaluating those 
individuals. We just need to be able to efficiently move to 
hire them.
    What the Choice Act did was to give us more positions in 
primary care and mental health in rural areas and in areas 
where there is not access to care. The goal will be to train 
people in communities where they may go back to practice. VA 
once again has the opportunity to say: Let's try to look for 
the best and let's hire them for the VA, but let's do it 
efficiently.
    Mr. Takano. You know what, I did get a call from a 
gastroenterologist, a young one, working at the USC medical 
facility in Los Angeles, and expressed extreme frustration at 
not being communicated with. This person has applied for a 
vacancy at gastroenterology at the LA VA hospital. And so I am 
beginning to understand what made on Hawaii this frustration. 
What do we need to do to bring through this inefficiency? I 
mean, do you have a plan? Have you pinpointed where the 
bottlenecks are?
    Dr. Lynch. The bottlenecks, Congressman, are the fact that 
we don't move fast enough and that we don't give people 
commitment soon enough. I was talking to Mr. Hernandez before 
the subcommittee hearing, and we have mechanisms in place now 
where we can offer a job a year in advance of the completion of 
their program. That means we can identify the people we want, 
we can offer them the job. The only condition is that they have 
to complete their training. But otherwise, we have an 
opportunity to take advantage of these educational training 
programs that we have. And we haven't been doing it, but we 
need to.
    Elias, do you want to comment briefly on how we can begin 
to recruit and get these people sooner?
    Mr. Hernandez. Yes. Thank you, Dr. Lynch.
    Going back to my original point is taking advantage of the 
flexibilities we have on the Title 38 and Title 38 hybrids 
appointing authority. We can engage in early conversations with 
the residents so we can get their commitments with the 
condition that once they complete their training program we 
will be able to convert them into permanent employees for the 
organization.
    Mr. Takano. What about people who already are trained and 
certified and are applying for vacancies?
    Mr. Hernandez. Congressman, I will tell you that we have a 
very aggressive national recruitment program, and I, personally 
speaking, would like to know a little bit more about that 
particular individual because gastroenterology is one of the 
most critical occupations we have in the organization. And our 
national recruiters are dedicated staff that deal directly with 
those individuals to engage with them early on in the process 
and walk them through the entire onboarding process.
    Mr. Takano. I will be happy to furnish the names to you.
    Mr. Hernandez. I would love to have it, Congressman.
    Dr. Benishek. Thank you. Thank you.
    Well, it is just funny that they are solving the problem, 
but your guy can't get a job after a year.
    Dr. Abraham.
    Dr. Abraham. I will add my frustration to Dr. Benishek's 
and to Dr. Wenstrup and evidently the panel's about having to 
log in every time that patient goes from room to room. Homeland 
security was one issue that you brought up, Dr. Lynch, but 
certainly on the civilian side we as physicians have to worry 
about HIPAA compliance if we let a record escape. The fines are 
very hefty. So we are under the gun, so to speak, as much the 
VA is and we understand.
    But if we have a computer system in the VA facility that 
the record can't move from computer to computer, then we do 
have a problem. And I am sure that they can, but the reason 
that they don't is I guess a question I do have, is like Dr. 
Benishek said, why can't that computer travel with the patient 
or just travel from room to room as the patient travels, just 
boot that record to another facility? The first question.
    And the second question, I only have two, you heard Mr. 
Morris' testimony, he was representing, I think, the American 
Board of Physician Specialties, as far as not being able to 
receive jobs in I guess the ratio that the ABMS was able to 
with their certification. Is there a disparity between those 
two specialties and even the AOA, the osteopathic physicians, 
and if so, why?
    Dr. Lynch. Congressman, I will be honest, this is the first 
I have heard of the concern today. I take it seriously because 
it is the potential opportunity to find more healthcare 
providers for the VA and for veterans. I will take it for the 
record to go back and find out a little more information about 
that and what has happened in the past.
    Dr. Abraham. I would appreciate if you would send that to 
me or just a followup. I would appreciate that.
    Dr. Lynch. Absolutely.
    Dr. Abraham. Okay. And the first question, what is the 
issue with the computers?
    Dr. Lynch. I share your frustration.
    Dr. Abraham. I know you do.
    Dr. Lynch. I have been there.
    Dr. Abraham. We are past Alexander Graham Bell and we 
actually have got some pretty good computers these days.
    Dr. Lynch. I grew up in an era when the phones were still 
dial and actually in an era when you had party lines, which was 
always kind of interesting.
    Dr. Abraham. I was also there.
    Dr. Lynch. I can carry a phone in my pocket now. We need to 
figure out a way how we can harness computers to work for us 
and not necessarily create obstacles for us.
    Mr. Abraham. And I appreciate that. And again, my request 
is that you please look into that, because it shouldn't be that 
hard with the computer systems we have now.
    Mr. Chairman, I yield back.
    Dr. Benishek. Thank you.
    Anyone have any other questions?
    Go ahead.
    Ms. Brownley. I just wanted to make one final comment 
before we close here. And I just want to say I know that the 
employees within the VA, particularly in human services, and 
you, Mr. Hernandez, are working very, very hard every day. Ms. 
Clifford testified that you are working really hard every 
single day, and I believe that and I thank you for your 
service.
    I just believe that we need to do more, that you need more 
assistance, you need a larger team, and we have to streamline 
the rules that are made, and we have got to put on our 
commonsense thinking hats, if you will, and streamline this 
process.
    So I didn't want to close without you thinking that, 
because I believe that you are working very, very hard and the 
people who are working for you are working very, very hard. I 
just believe you need more people and we need to improve upon 
the rules.
    Mr. Hernandez. Thank you, ma'am, and we appreciate your 
support.
    Dr. Benishek. Thank you all once again for being here 
today. I think we have touched on several issues that are very 
important for our veterans, and I really appreciate the work 
that you do.
    The subcommittee may be submitting additional questions for 
the record. I would appreciate your assistance in ensuring an 
expedient response to those inquiries.
    Dr. Benishek. And if there are no further questions, the 
panel is excused. Thank you very much.
    Dr. Benishek. I ask unanimous consent that all members have 
5 legislative days to revise and extend their remarks and 
include extraneous material. Without objection, so ordered.
    Dr. Benishek. I would like to once again thank all of our 
witnesses and the audience members for joining us here this 
morning and this afternoon. And the hearing is now adjourned.
    [Whereupon, at 1:02 p.m., the subcommittee was adjourned.]

                                APPENDIX

          Prepared Statement of Joan Clifford, MSM, RN, FACHE

    Overcoming Barriers to More Efficient and Effective VA Staffing
    Chairman Benishek, Ranking Member Brownley and members of the 
Subcommittee, on behalf of the nearly 3,000 members of the Nurses 
Organization of Veterans Affairs (NOVA), I would like to thank you for 
the opportunity to testify on today's important and timely subject--VA 
Staffing.
    As the Department of Veterans' Affairs undergoes a system-wide 
reorganization to include the many challenges of implementing The 
Veterans Access, Choice and Accountability Act, staffing must be at the 
forefront of its evaluation. I am Joan Clifford, Deputy Nurse Executive 
at the VA Boston Health Care System and am here today as the immediate 
Past President of NOVA. NOVA is a professional organization for 
registered nurses employed by the VA.
    NOVA respects and appreciates what our labor organizations do for 
VA nurses. NOVA's focus is on professional issues not working 
conditions which are the purview of the union.
    NOVA is uniquely qualified to share its views on the ability of VA 
to effectively and efficiently recruit, on-board and retain qualified 
health care professionals to treat our veteran patients. As VA nurses, 
we are in the medical centers, community-based outpatient clinics and 
at the bedside every day. With this in mind, we have identified 
retention and recruitment of health care professionals as a critically 
important issue in providing the best care anywhere for our veterans 
and would like to offer the following observations.
    NOVA believes that the underlying issues reside in the lack of a 
strong infrastructure for Human Resources, insufficient nursing 
education opportunities, as well as the complex application system--USA 
Jobs--that the VHA utilizes for hiring staff.
    VHA is facing a shortage of both corporate experience, and a lack 
of sufficient HR staffing to support the multiple priorities required 
for hiring health care professionals.
    USA Jobs is a complex hiring process. The system is very slow to 
review applications online, adding days, even weeks to the time it 
takes to create a complete qualification review. Upcoming enhancements 
in HR such as Web HR and HR Smart have to be able to interface with USA 
Jobs. Some candidates have had to wait five months while HR processed 
their applications. This results in candidates accepting non-VA jobs, 
and puts VA back in the hunt for another qualified candidate.
    HR employees often have limited knowledge of direct hiring process 
for Registered Nurses, resulting in unnecessary recruitment delays. HR 
has also been faced with multiple initiatives, policies and Human 
Resources Management letters with unclear instructions and guidance. 
Additionally, current VA process and policies for obtaining recruitment 
and retention incentives can also cause significant delays in hiring 
personnel.
    All levels of support personnel, as well as RN's, are impacted by 
the current inflexibilities in pay structure and years of flat lined 
and non-existent pay increases. Reclassification and downgrades of some 
occupations such as Surgical Technicians who were brought in at the GS7 
level, and have recently been downgraded to GS5 are making it 
impossible to competitively recruit and retain. Additionally, the 
increased availability of private sector jobs due to retirements and 
program expansions within the Affordable Care Act has created other 
hurdles for VA.
    Locality pay challenges, which directly influences RN pay, have 
once again been brought up by Medical Center leadership. Due to the 
lack of corporate knowledge among staff within HR on how to maximize 
the law inconsistent application of the Pay Law remains an obstacle of 
hiring. NOVA asks that the ceiling on nurse pay be increased to prevent 
compression between the grades in order to remain competitive.
    Ensuring an infrastructure of knowledgeable education leaders 
within VHA is also critical to support programs that produce nursing 
graduates who honor and respect Veterans Programs. These programs are 
often key to hiring opportunities at the Post Baccalaureate Nurse 
residency and the Nurse Practitioner residency level within VA.
    Nursing residents from these programs are embedded in the VA and 
have the opportunity to demonstrate clinical competency as well as 
apply for available positions. An increase to the nursing education 
infrastructure budget is needed to provide for more senior nursing 
leaders who initiate and manage these programs.
    Tuition reimbursement and loan forgiveness monies should also be 
enhanced in order to help new nurses defray the cost of their education 
if they work for VHA. The Office of Academic Affairs has supported a 
wonderful RN Residency Program across some VA's, but funds are limited 
thus potentially impacting the recruitment of future RN hires who flock 
to these programs. Programs that already exist, such as the Health 
Professional Scholarship Programs, which allow the VA to recruit nurses 
by paying their tuition in exchange for a service commitment after 
licensure, need to be considered an important part of funding 
methodology.
    Funding is also needed to support VA Nursing Academic partnerships 
which enables VA and School of Nursing faculty to develop and implement 
Post Baccalaureate Nurse Residency (PBNR) and Nurse Practitioner 
Residency programs (NPRP). The PBNR has had an impressive impact on 
nursing recruitment and retention. The PBNR had 100% retention of 
employed nurses after one year of employment as compared to the overall 
loss rate of 10% in other practices. The nurse practitioner residency 
program has found that residents overwhelming wish to work in the VA. 
The NPRP program is currently a pilot and will require sustained 
funding to pay for resident stipends and education infrastructure for 
the educational programs and infrastructure for VA Nursing. NOVA 
believes it is a good investment as hiring NP's will increase access 
and enable additional services to veterans needing care nationwide.
    Another area of concern is the use of Advanced Practice Nurses 
(APRNs), which at this time, are subject to the state laws in which the 
facility is located. If a state has a physician supervisory or 
collaborative relationship in their regulations, then APRNs are not 
allowed to practice autonomously to the full scope of their abilities. 
Currently there are 20 states and the District of Columbia that have 
Full Practice Authority laws in place; in those states and the 
district, VA APRNs are allowed to practice to the full extent of their 
scope. However, in the other remaining states this is not permissible.
    VHA is advocating for ``Full Practice Authority'' which would 
result in APRNs employed by the VA to function to the full extent of 
their education, licensure, and training, regardless of what state they 
live and work. Legislation has been introduced, H.R. 1247, the 
``Improving Veterans Access to Care Act of 2015,'' which is the model 
already practiced by the Department of Defense, Indian Health Service 
and the Public Health Service systems. NOVA, together with the American 
Nurses Association, American Association of Colleges of Nursing, 
American Association of Nurse Practitioners, American Association of 
Nurse Anesthetists, National Association of Clinical Nurse Specialists 
and the American College of Nurse-Midwives are calling on Congress to 
support this legislation which would begin to address critical needs 
within VA facilities by improving wait times and access to care for all 
veterans.
    In closing, NOVA would like to add that the past year's negative 
publicity surrounding the scheduling and access crisis within VA has 
also had an impact on recruiting potential applicants. VA employs over 
90,000 nurses, which is about one third of its health care workforce. 
NOVA believes that there is no greater time to have representatives 
from the Office of Nursing Services at the table as VA reorganizes the 
way it provides care and services to America's heroes
    Improvements and careful review of the process of downgrades across 
VA, increased training and utilization of Locality Pay law, revising 
the cap on the RN Pay schedule to eliminate compression, as well as 
establishing a more user friendly application process and supporting HR 
offices across the U.S. will go a long way towards correcting the 
challenges VHA faces with staffing.
    NOVA once again thanks you for this opportunity to testify and I 
would be pleased to answer any questions from the committee.
    Statement on Receipt of Grants or Contract Funds: Neither Ms. Joan 
Clifford, nor the organization she represents, the Nurses Organization 
of Veterans Affairs, has received federal grant or contract funds 
relevant to the subject matter of this testimony during the current or 
past two fiscal years.


[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

               Prepared Statement of Dr. Nichol L. Salvo

    Chairman Benishek, Ranking Member Brownley and members of the 
Subcommittee, I welcome and appreciate the opportunity to testify 
before you today on behalf of the American Podiatric Medical 
Association (APMA). I commend this Subcommittee for its focus to assist 
and direct the Veterans Administration (VA) to effectively and 
efficiently recruit and retain qualified medical professionals to treat 
veteran patients and improve access to quality health care in the VA 
system by addressing the lengthy and burdensome credentialing and 
privileging process.
    I am Dr. Nichol Salvo, member and Director of Young Physicians' at 
the American Podiatric Medical Association (APMA). I am also a 
practicing VA physician, maintaining a Without Compensation (WOC) 
appointment status. I am before you today representing APMA and the 
podiatric medical profession, and specifically our members currently 
employed, and those seeking to be employed, by VA. While I do not 
represent VA in my capacity today, I do bring with me first-hand 
experience and knowledge of hiring practices within VA, as well as 
knowledge of the widespread disparity between podiatric physicians and 
other VA physicians.
    APMA is the premier professional organization representing 
America's Doctors of Podiatric Medicine who provide the majority of 
lower extremity care, both to the public and veteran patient 
populations. APMA's mission is to advocate for the profession of 
podiatric medicine and surgery for the benefit of its members and the 
patients they serve.
    Mr. Chairman, when the Veterans Health Administration (VHA) 
qualification standards for podiatry were written and adopted in 1976, 
I was not yet born. Podiatric education, training and practices in 1976 
starkly contrasted with that of other physician providers of the time, 
and with podiatric medicine as it is today. Unlike thirty-nine years 
ago, the current podiatric medical school curriculum is vastly expanded 
in medicine, surgery and patient experiences and encounters, including 
whole body history and physical examinations. In 1976, residency 
training was not required by state scope of practice laws. Today, every 
state in the nation, with the exception of four, requires post-graduate 
residency training for podiatric physicians and surgeons. In 1976, 
podiatric residency programs were available for less than 40 percent of 
graduates. Today there are 597 standardized, comprehensive, three-year 
medicine and surgery residency positions to satisfy the number of our 
graduates, with 77 positions (or 13 percent) housed within the VA. In 
contrast to 1976, today's residency programs mandate completion of a 
broad curriculum with a variety of experiences and offer a direct 
pathway to board certification with both the American Board of 
Podiatric Medicine (ABPM) and the American Board of Foot and Ankle 
Surgery (ABFAS). These certifying bodies are the only certifying 
organizations to be recognized by the Council on Podiatric Medical 
Education (CPME) and VA. These bodies not only issue time-limited 
certificates, but they participate in the Centers for Medicare and 
Medicaid Services (CMS) Maintenance of Certification (MOC) 
reimbursement incentive program. Unlike the residency curricula in 1976 
(which were not standardized, nor comprehensive), today's residency 
curriculum is equitable to MD and DO residency training and includes 
general medicine, medical specialties such as rheumatology, dermatology 
and infectious disease, general surgery and surgical specialties such 
as orthopedic surgery, vascular surgery and plastic surgery. CPME-
approved fellowship programs did not exist in 1976, but since their 
creation in 2000, they offer our graduates opportunities for additional 
training and sub-specialization. Today, podiatric physicians are 
appointed as medical staff at the vast majority of hospitals in the 
United States, and many serve in leadership roles within those 
institutions, including but not limited to chief of staff, chief of 
surgery, and state medical boards. Many of my colleagues have full 
admitting privileges and are responsible for emergency room call as 
trauma and emergency medicine are now also incorporated into post-
graduate training. The competency, skill and scope of today's podiatric 
physicians are vastly expanded and truly differ from the podiatrist 
that practiced before I was born. Because of this, CMS recognizes 
today's podiatrists as physicians, and Tricare recognizes us as 
licensed, independent practitioners.
    The total number of VA enrollees has increased from 6.8 million 
in2002 to 8.9 million in 2013 (1). While we are slowly losing our 
Vietnam veteran population, we are gaining a solid base of Operation 
Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) patients, 
returning from war with their unique lower extremity issues. The 
projected patient population of Gulf War Era veterans is expected to 
increase from 30 percent in 2013 to approximately 55 percent in 2043 
(1). The number of service-connected disabled veterans has increased 
from approximately 2.2 million in 1986 to 3.7 million in 2013 (1). Over 
90 percent of disabled veterans were enrolled in VHA in 2012 (1). The 
likelihood of service-connected disabled veterans seeking VA health 
care generally increases with the veteran's disability rating (1). The 
majority of male veterans who are currently seeking care from VA served 
during the Vietnam era (1).
    As a matter of fact, veteran patients are ailing and have more 
comorbid disease processes than do age-matched Americans (2, 3, 4, 5, 
6). This includes major amputation, where age-specific rates are 
greater in the VHA compared to the US rates of major amputation (7). 
Elderly enrolled veterans have substantial disease burden with 
disproportionately poor health status compared to the same age enrolled 
in Medicare (8). The prevalence of diabetes is substantially greater 
among veteran patients compared to the general population, and 
unfortunately, the prevalence is trending up (6). While diabetes 
affects 8 percent of the US population, 20 percent of veteran patients 
carry this diagnosis (9).The aging veteran population combined with 
these increased rates of diabetes has increased the burden of diabetic 
foot ulcers and amputations (10). Veteran patients with one or more 
chronic diseases account for 96.5 percent of total VHA health care (9). 
In addition to diabetes, some of the most common chronic conditions 
documented in our veteran patients manifest in the lower extremity such 
as hyperlipidemia, coronary artery disease, chronic obstructive 
pulmonary disease, and heart failure.(9).
    Socioeconomic and psychosocial issues often plague our veterans and 
further complicate disease management. Veteran patients statistically 
have lower household incomes than non-veteran patients (1). Sadly, many 
of our veterans are homeless and suffer from comorbid conditions such 
as diabetic foot ulcers, sometimes with a level of amputation, so 
management of this patient population can be extremely challenging. 
Health care expenses combined with disability and compensation coverage 
account for the majority of VA utilization and have demonstrated 
significant growth since 2005 (1).
    This is my patient population, Mr. Chairman. I serve patients who 
are statistically comorbid with psychosocial and socioeconomic issues, 
all of which play a role in my delivery of care and final outcome. I 
know first-hand, with private practice experience and VA experience, 
that the veteran population is far more complex to treat than patients 
in the private sector, as a whole. Greater than 90% of the veteran 
podiatric patient population is 44 years and older, with the majority 
of our patients of the Vietnam era, who are plagued by the long-term 
effects of Agent Orange. Because of this and because of the increasing 
number of OEF, OIF, and Operation New Dawn (OND) veterans with lower 
extremity conditions, one of our major missions as providers of lower 
extremity care is amputation prevention and limb salvage. The value of 
podiatric care is recognized in at-risk patient populations. Podiatric 
medical care as part of the interdisciplinary team approach reduces the 
disease and economic burdens of diabetes. In a study of 316,527 
patients with commercial insurance (64 years of age and younger) and 
157,529 patients with Medicare and an employer sponsored secondary 
insurance, there was noted a savings of $19,686 per patient with 
commercial insurance and a savings of $4,271 per Medicare-insured 
patient, when the patients had at least one visit to a podiatric 
physician in the year preceding their ulceration (11). Nearly 45,000 
veterans with major limb loss use VA services each year. Another 1.8 
million veterans within the VA Healthcare Network are at-risk of 
amputation. These at-risk veterans include 1.5 million with diabetes, 
400,000 with sensory neuropathy, and 70,000 with non-healing foot 
ulcers (12). Despite having a large at-risk patient population from the 
Vietnam era, VA podiatric physicians are seeing increasing numbers of 
OEF, OIF and OND patients who are at-risk for amputation. From FY 2001 
to 2014, the number of foot ulcers increased in the OEF, OIF, and OND 
populations from 17 documented cases to 612 (12). Despite our 
statistics of at-risk patients, lower extremity amputation rates among 
all veteran patients decreased from approximately 11,600 to 4,300 
between fiscal year 2000 and 2014 (12). Given the magnitude of 
amputation reductions, podiatric physicians not only provide a cost-
savings to VA, but we also play an integral role in the veteran quality 
of life (12).
    While limb salvage is a critical mission of the podiatry service in 
the VA, the care delivered by the podiatric physician is of much 
broader scope. As the specialist of the lower extremity, we diagnose 
and treat problems ranging from dermatological issues to falls 
prevention to orthopedic surgery. As one of the top five busiest 
services in VA, we provide a significant amount of care to our veteran 
patients and the bulk of foot and ankle care specifically. In fiscal 
year 2014, the foot and ankle surgical procedures rendered by the 
podiatry services totaled 4,794, while foot and ankle surgical 
procedures performed by the orthopedic surgery service was a sum total 
of 72.
    The mission of VA health providers is to maintain patient 
independence and keep the patient mobile by managing disease processes 
and reducing amputation rates. Podiatric physicians employed by VA 
assume essentially the same clinical, surgical, and administrative 
responsibilities as any other unsupervised medical and surgical 
specialty. Podiatrists independently manage patients medically and 
surgically within our respective state scope of practice, including 
examination, diagnosis, treatment plan and follow-up. In addition to 
their VA practice, many VA podiatrists assume uncompensated leadership 
positions such as residency director, committee positions, clinical 
manager, etc. Examples include:

         Steve Goldman, DPM, Site Director for Surgical 
        Service, Department of Veterans Affairs - New York Harbor 
        Health Care System;
         William Chagares, DPM, Research Institutional Review 
        Board Co-Chair, Chair of Research Safety Committee and Research 
        Integrity Officer and Chair of Medical Records Committee at the 
        James A. Lovell Federal Heath Care Center;
         Aksone Nouvong, DPM, Research Institutional Review 
        Board Co-Chair at the West Los Angeles VA;
         Lester Jones, DPM the former Associate Chief of Staff 
        for Quality at the VA Greater Los Angeles Health Care System 
        for eight years, and podiatric medical community representative 
        while serving on the VA Special Medical Advisory Group; and
         Eugene Goldman, DPM formerly the Associate Chief of 
        Staff for Education at Lebanon VA;

    Despite this equality in work responsibility and expectations, 
there exists a marked disparity in recognition and pay of podiatrists 
as physicians in the VA. These discrepancies have directly resulted in 
a severe recruitment issue of experienced podiatrists into the VA, and 
unfortunately have also been the direct cause of retention issues. The 
majority of new podiatrists hired within the VA have stories just like 
mine. They have less than ten years of experience and they are not 
board certified. As a result of the disparity the VA is attracting less 
experienced podiatric physicians. After hiring, the majority of these 
new podiatrists that hire into the VA separate within the first 5 
years. I am speaking from personal experience, Mr. Chairman. As stated 
earlier, I am one of the majority. I entered the VA with less than five 
years of experience and was not board certified at the time. I gained 
my experience, earned my board certification, and separated from the VA 
to take a leadership position with my parent organization. I will 
forever remain loyal to VA, which is why I still voluntarily treat 
patients at my local facility, without compensation. Having worked 
inside and outside the VA, I can truly attest to the disparity that 
exists.
    Compounding the recruitment and retention issues, there exists 
lengthy employment vacancies when a podiatrist leaves a station. The 
gap between a staff departure to the time of filling the position is in 
excess of one year. I am personally aware that my position was assumed 
by a podiatric physician 14 months after my separation. Because of 
employment gaps as a consequence of the inherent and chronic 
recruitment and retention challenges, wait times within the VA for 
lower extremity care are unacceptably long. Since October 2014, 22,601 
of the 191,501 (11.8 percent) established patients suffered a wait time 
of greater than 15 days, with some greater than 120 days. During this 
same time period, 23,543 of the 25,245 (93 percent) new patients 
suffered a wait time of the same magnitude. The prolonged vacancy 
exists partly because the VA is not capable of attracting experienced 
candidates, but also because the credentialing process is ineffectively 
burdensome. My credentialing process for my recent two without 
compensation (WOC) appointments was 11 months and 5 months, 
respectively. Those are 16 months of missed opportunity to treat 
patients, but instead, I was needlessly waiting, as were the patients
    It is precisely because of the aforementioned issues that 
legislative proposals to amend Title 38 to include podiatric physicians 
and surgeons in the Physician and Dentist pay band, have been submitted 
by the Director of Podiatry Services annually for the last ten years. 
These proposals have been denied every single year. Additionally, 
several requests for an internal fix have been denied, despite written 
letters of support for this movement from the former Under Secretary of 
Health, Robert Petzel, MD.
    Five years ago the APMA's House of Delegates passed a resolution 
making this issue a top priority. Since then we have alerted the VA to 
our knowledge of this issue. In response, former Under Secretary Petzel 
created a working group composed of Dr. Rajiv Jain, now Assistant 
Deputy Under Secretary for Health for Patient Care Services, Dr. 
Margaret Hammond, Acting Chief Officer for Patient Care Services, and 
Dr. Jeffrey Robbins, Chief of Podiatry Service. We have participated in 
several meetings with members of the working group and, most recently, 
we have received written support of Patient Care Services and Podiatry 
Service for a legislative solution to address this issue.
    Occam's razor is a problem solving principle whereby the simplest 
solution is often the best. I come before this committee today to 
respectfully request that Congress help the VA and its patients by 
passing legislation to recognize podiatric physicians and surgeons as 
physicians in the physician and dentist pay band. We believe that 
simply changing the law to recognize podiatry, both for the 
advancements we have made to our profession and for the contributions 
we make in the delivery of lower extremity care for the veteran 
population, will resolve recruitment and retention problems for VA and 
for veterans. Mr. Chairman and members of the Subcommittee, thank you 
again for this opportunity. This concludes my testimony and I am 
available to answer your questions.
    1. National Center for Veterans Analysis and Statistics, Department 
of Veterans Affairs http://www.va.gov/vetdata/index.asp.
    2. Singh JA. Accuracy of Veterans Affairs databases for diagnoses 
of chronic diseases. Prev Chronic Dis. 2009 Oct;6(4):A126.
    3. Olson JM, Hogan MT, Pogach LM, Rajan M, Raugi GJ, Reiber GE. 
Foot care education and self management behaviors in diverse veterans 
with diabetes. Patient Prefer Adherence. 2009 Nov 3;3:45-50.
    4. Powers BJ, Grambow SC, Crowley MJ, Edelman DE, Oddone EZ. 
Comparison of medicine resident diabetes care between Veterans Affairs 
and academic health care systems. J Gen Intern Med. 2009 Aug;24(8):950-
5.
    5. Agha Z, Lofgren RP, VanRuiswyk JV, Layde PM. Are patients at 
Veterans Affairs medical centers sicker? A comparative analysis of 
health status and medical resource use. Arch Intern Med. 2000 Nov 
27;160(21):3252-7.
    6. Miller DR, Safford MM, Pogach LM. Who has diabetes? Best 
estimates of diabetes prevalence in the Department of Veterans Affairs 
based on computerized patient data. Diabetes Care. 2004 May;27 Suppl 
2:B10-21.
    7. Mayfield JA, Reiber GE, Maynard C, Czerniecki JM, Caps MT, 
Sangeorzan BJ. Trends in lower limb amputation in the Veterans Health 
Administration, 1989-1998. J Rehabil Res Dev. 2000 Jan-
110011000Feb;37(1):23-30.
    8. Selim AJ, Berlowitz DR, Fincke G, Cong Z, Rogers W, Haffer SC, 
Ren XS, Lee A, Qian SX, Miller DR, Spiro A 3rd, Selim BJ, Kazis LE. The 
health status of elderly veteran enrollees in the Veterans Health 
Administration. J Am Geriatr Soc. 2004 Aug;52(8):1271-6.
    9. Neugaard BI, Priest JL, Burch SP, Cantrell CR, Foulis PR. 
Quality of care for veterans with chronic diseases: performance on 
quality indicators, medication use and adherence, and health care 
utilization. Popul Health Manag. 2011 Apr;14(2):99-106.
    10. Johnston MV, Pogach L, Rajan M, Mitchinson A, Krein SL, 
Bonacker K, Reiber G. Personal and treatment factors associated with 
foot self-care among veterans with diabetes. J Rehabil Res Dev. 2006 
Mar-Apr;43(2):227-38.
    11. Carls GS, Gibson TB, Driver VR, Wrobel JS, Garoufalis MG, 
Defrancis RR, Wang S, Bagalman JE, Christina JR. The economic value of 
specialized lower-extremity medical care by podiatric physicians in the 
treatment of diabetic foot ulcers. J Am Podiatr Med Assoc. 2011 Mar-
Apr;101(2):93-115.
    12. Preventing Amputation in Veterans Everywhere (PAVE) Program
    
    
    
   [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT] 
    
    
    
    
                                 [all]