[House Hearing, 115 Congress]
[From the U.S. Government Publishing Office]
LEGISLATIVE HEARING ON H.R. 2787; H.R. 3696; H.R. 5521; H.R. 5693; H.R.
5864; H.R. 5938; H.R. 5974; AND H.R. 6066
=======================================================================
HEARING
before the
SUBCOMMITTEE ON HEALTH
of the
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED FIFTEENTH CONGRESS
SECOND SESSION
__________
WEDNESDAY, JUNE 13, 2018
__________
Serial No. 115-66
__________
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.govinfo.gov
______
U.S. GOVERNMENT PUBLISHING OFFICE
35-729 WASHINGTON : 2019
COMMITTEE ON VETERANS' AFFAIRS
DAVID P. ROE, Tennessee, Chairman
GUS M. BILIRAKIS, Florida, Vice- TIM WALZ, Minnesota, Ranking
Chairman Member
MIKE COFFMAN, Colorado MARK TAKANO, California
BILL FLORES, Texas JULIA BROWNLEY, California
AMATA COLEMAN RADEWAGEN, American ANN M. KUSTER, New Hampshire
Samoa BETO O'ROURKE, Texas
MIKE BOST, Illinois KATHLEEN RICE, New York
BRUCE POLIQUIN, Maine J. LUIS CORREA, California
NEAL DUNN, Florida CONOR LAMB, Pennsylvania
JODEY ARRINGTON, Texas ELIZABETH ESTY, Connecticut
CLAY HIGGINS, Louisiana SCOTT PETERS, California
JACK BERGMAN, Michigan
JIM BANKS, Indiana
JENNIFFER GONZALEZ-COLON, Puerto
Rico
BRIAN MAST, Florida
Jon Towers, Staff Director
Ray Kelley, Democratic Staff Director
SUBCOMMITTEE ON HEALTH
NEAL DUNN, Florida, Chairman
GUS BILIRAKIS, Florida JULIA BROWNLEY, California,
BILL FLORES, Texas Ranking Member
AMATA RADEWAGEN, American Samoa MARK TAKANO, California
CLAY HIGGINS, Louisiana ANN MCLANE KUSTER, New Hampshire
JENNIFER GONZALEZ-COLON, Puerto BETO O'ROURKE, Texas
Rico LUIS CORREA, California
BRIAN MAST, Florida
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
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Wednesday, June 13, 2018
Page
LEGISLATIVE HEARING ON H.R. 2787; H.R. 3696; H.R. 5521; H.R.
5693; H.R. 5864; H.R. 5938; H.R. 5974; AND H.R. 6066........... 1
OPENING STATEMENTS
Honorable Neal Dunn, Chairman.................................... 1
Honorable Julia Brownley, Ranking Member......................... 2
WITNESSES
The Honorable Vicky Hartzler, U.S. House of Representatives, 4th
District; Missouri............................................. 3
Prepared Statement........................................... 27
The Honorable Brad Wenstrup, U.S. House of Representatives, 2nd
District; Ohio................................................. 4
Prepared Statement........................................... 28
The Honorable Clay Higgins, U.S. House of Representatives, 3rd
District; Louisiana............................................ 6
Prepared Statement........................................... 29
The Honorable Mike Bost, U.S. House of Representatives, 12th
District; Illinois............................................. 7
Prepared Statement........................................... 30
The Honorable Jenniffer Gonzalez-Colon, U.S. House of
Representatives, Puerto Rico................................... 9
Prepared Statement........................................... 31
The Honorable Jeff Denham, U.S. House of Representatives, 10th
District; California........................................... 10
Prepared Statement........................................... 32
The Honorable Matt Cartwright, U.S. House of Representatives,
17th District; Pennsylvania, prepared statement only........... 33
The Honorable Marcy Kaptur, U.S. House of Representatives, 9th
District; Ohio, prepared statement only........................ 33
Roscoe Butler, Deputy Director for Health Care, Veterans Affairs
and Rehabilitation, The American Legion........................ 11
Prepared Statement........................................... 35
Jeremy Villanueva, Associate National Legislative Director,
Disabled American Veterans..................................... 13
Prepared Statement........................................... 39
Kayda Keleher, Associate Director, National Legislative Service,
Veterans of Foreign Wars of the United States.................. 15
Prepared Statement........................................... 44
Jessica Bonjorni MBA, PMP, SPHR, Acting Assistant Deputy Under
Secretary for Health for Workforce Services, Veterans Health
Administration, U.S. Department of Veterans Affairs............ 16
Prepared Statement........................................... 47
Accompanied by:
Dayna Cooper MSN, RN, Director, Home and Community-Based
Programs, Veterans Health Administration, U.S. Department
of Veterans Affairs
STATEMENT FOR THE RECORD
AMERICAN FEDERATION OF GOVERNMENT EMPLOYEES, AFL-CIO (AFGE)...... 53
American Orthotic and Prosthetic Association..................... 54
Military Officers Association of America (MOAA).................. 57
Paralyzed Veterans of America (PVA).............................. 60
LEGISLATIVE HEARING ON H.R. 2787; H.R. 3696; H.R. 5521; H.R. 5693; H.R.
5864; H.R. 5938; H.R. 5974; AND H.R. 6066
----------
Wednesday, June 13, 2018
U.S. House of Representatives,
Committee on Veterans' Affairs,
Subcommittee on Health
Washington, D.C.
The Subcommittee met, pursuant to notice, at 3:00 p.m., in
Room 334, Cannon House Office Building, Hon. Neal P. Dunn
[Chairman of the Subcommittee] presiding.
Present: Representatives Dunn, Higgins, Gonzelez-Colon,
Brownley, Kuster, and Correa.
Also Present: Representative Bost.
OPENING STATEMENT OF NEAL DUNN, CHAIRMAN
Mr. Dunn. The Subcommittee will come to order.
Before we begin I would like to ask unanimous consent for
Congressman Mike Bost from Illinois to sit on the dais and
participate in today's proceedings. Without objection, that is
so ordered.
I want to thank you all for joining us.
This afternoon we will be discussing eight bills that have
been referred to the Subcommittee on Health. These bills are
sponsored by Committee Members and our non-committee colleagues
alike from Members on both sides of the aisle.
I am grateful to each of the bills' sponsors for their
interest in ensuring that the Department of Veterans Affairs is
the best equipped to provide high quality care and services
that our Nation's veterans have earned and certainly deserve.
The bills that we will be discussing this afternoon cover a
wide variety of topics. For example, our agenda includes bills
that pertain to noninstitutional long-term care and clinical
productivity, efficiency, and medical waste management. Also,
some of the bills on our agenda today address some aspects of
recruitment and retention. The considerable challenges that VA
has faced in recent years when it comes to hiring have been
well documented in this Subcommittee.
Next Thursday we will be holding another hearing to
evaluate what, if any, progress the VA has made with the
additional authorities that this Congress has provided to
improve the VA's abilities to recruit new hires, bring them on
board, and retain them over the course of their careers.
I hope that that hearing reveals headway in meeting
staffing needs across the VA health care system. However, as
long as the staffing concerns remain a problem for the VA, this
Subcommittee will continue to prioritize finding innovative
ways to ensure that the VA is able to hire doctors and nurses
and other providers that our veterans need.
Once again I want to thank the bill sponsors for
introducing their thoughtful proposals and for their attendance
here today.
I also want to thank the veterans service organizations who
will be testifying or who have submitted statements for the
record and for their willingness to lend their opinions and
insights to us this afternoon.
Mr. Dunn. And finally, I am grateful to the witnesses from
the VA for being here to provide the Department's perspective
on these bills.
That said, I do want to note my disappointment that despite
being provided with several weeks' notice of this hearing, VA's
testimony did arrive late to the Committee staff.
We read your testimony carefully. We consider it seriously.
And we would like to have more than 48 hours to study it. I
found the testimony to be very useful once it was received, and
I hope the next time we will be able to get that in a little
more timely fashion.
I now yield to Ranking Member Brownley for any opening
statement that she may have.
OPENING STATEMENT OF JULIA BROWNLEY, RANKING MEMBER
Ms. Brownley. Well, thank you, Mr. Chairman, and I am
looking forward to this hearing.
And I wanted to welcome back my friend, Dr. Wenstrup. We
worked very closely together on this Subcommittee.
So welcome back.
And I, too, want to thank the VA and our veterans service
organizations for being here today. We have some great
legislation that we are considering, and your expertise and
input is so valuable to us as we consider what changes need to
be made to best help our veterans.
The bills before the Subcommittee today are practical
solutions to issues affecting veteran's nation-wide. In
particular, I am concerned about the persistent number of
vacancies at the VA and feel that we must do more to bring
qualified doctors, nurses, and other medical providers into the
VA system.
Hiring and retention within the VA has long been
problematic, and today a number of the bills seek to assist VA
in attracting qualified health care providers to treat our
veterans.
While we know VA offers a high quality of care, it is often
a lack of access that can be frustrating for our veteran
patients. By focusing on VA's HR department and premedical
school training programs, we can ensure VA has a pipeline of
providers entering the VA and the staff to ensure they are on
board in a timely manner.
I look forward to further discussions of these bills and
welcome any suggestions on how we can improve upon them. I
thank all of our colleagues for being here and for their work
supporting veterans.
Thank you, Mr. Chairman, and I yield back.
Mr. Dunn. Thank you very much, Ms. Brownley.
I will now introduce our first panel. It is a pleasure to
be joined today by several of our bills' sponsors. With us are
Congresswoman Vicky Hartzler from Missouri and Congressman Brad
Wenstrup from Ohio. And he is former Chairman of this
Committee, Dr. Wenstrup. I will introduce the other witnesses.
Actually, we also have Congressman Mike Bost from Illinois
is going to be a witness on the panel, and also Congressman
Clay Higgins from Louisiana.
I appreciate all of you taking time out from your afternoon
here to discuss your legislation.
Mrs. Hartzler, you are now recognized for 5 minutes.
STATEMENT OF THE HONORABLE VICKY HARTZLER
Mrs. Hartzler. Well, thank you, Chairman Dunn and Ranking
Member Brownley and distinguished Members of the Subcommittee.
I appreciate you allowing me time to testify on H.R. 5521, the
VA Hiring Enhancement Act.
Our veterans deserve the best. Unfortunately, top notch
care is often hampered by a shortage of doctors at the VA.
I believe that this bill, which I introduced along with
Congressman Correa and Congressman Bost, will help the VA to
fill some of these vacancies.
Our bill has three main provisions.
First, it would allow physicians to be released from
noncompete agreements only for the purpose of serving in the VA
for at least 1 year. Noncompete agreements are supposed to
prevent a physician from building up a patient base and then
taking those patients with them as they set up their own
practice. A physician moving to the VA simply does not fit this
description.
This proven provision would ensure that a noncompete
agreement is never used to keep a physician from serving
veterans at a VA facility and only applies to such a
circumstance.
Second, our bill updates the minimum training requirement
for VA physicians. Completion of a medical residency is widely
accepted as standard comprehensive training for clinical
physicians in the United States; however, current law only
requires that a physician be licensed in order to treat
veterans. In the case of some medical specialties, the
difference between licensing and completing residency can
represent 6 years of training.
Some have suggested this provision would exacerbate the
shortage of physicians at the VA by shrinking the pool from
which the VA can hire; however, the VA currently hires almost
exclusively those physicians which have completed residency
training, so this provision would not result in such an impact.
Others have rightly submitted that veterans are largely
satisfied with the quality of care they receive at the VA.
They, therefore, submit that we do not need a legislative fix
to a higher standard. I contend that as long as Congress sees
fit to impose any standard on the VA regarding those caring for
veterans, we have a duty to ensure that that standard is
appropriate.
Completion of residency training is the accepted standard
in this Nation, and we should never expect veterans to accept
anything less. This is a commonsense update to something
Federal law already addresses and ensures that only fully
trained physicians care for those who served our Nation.
Finally, our bill would place veterans' hospitals on a
level playing field with the private sector when it comes to
recruiting timelines. Often, private sector health care
providers begin recruiting medical residents as they begin
their final year of residency, sometimes even earlier. Most
residents have school debt they need to start paying off, an
average of $190,000. During residency they treat patients and
work upwards of 80 hours a week, sometimes with single shifts
up to 28 hours.
These residents, rightfully motivated to secure a post-
residency job with better pay and better hours, often accept a
solid job offer from the private sector before VA recruiters
are able to get their recruiting process even started.
Our bill authorizes VA recruiters to make job offers to
physicians up to 2 years prior to fulfilling all of the VA's
requirements contingent on meeting all requirements before they
begin treating veterans. It offers job security to medical
residents who want to work at the VA when they complete their
training. And it allows VA facilities and recruiters to shore
up appointments further in advance, helping them to plan and
forecast medical workforce needs.
VA recruiters are already pitching a great opportunity for
physicians, and we owe them policies that make them as
competitive as possible with private sector recruiters. I
believe that advancement of this legislation will help begin to
fill the VA's many vacant health care position needs.
We have worked closely with this Committee's staff, VA
recruiters, and VSOs on this bill, and I am pleased to report
that it has garnered wide support, including formal endorsement
from the American Legion and Paralyzed Veterans of America. It
is my hope we can work together to move this bill to the House
floor soon.
Thank you again for allowing me this time, and I yield
back.
[The prepared statement of Vicky Hartzler appears in the
Appendix]
Mr. Dunn. Thank you very much Representative Hartzler.
We now recognize Dr. Wenstrup for 5 minutes.
STATEMENT OF THE HONORABLE BRAD R. WENSTRUP
Mr. Wenstrup. Thank you very much, Mr. Chairman, Ranking
Member Brownley. It is good to be with you all again. I
appreciate the opportunity to be with you today.
As a Member of the House Veterans Affairs Committee for
many years, one of my frustrations was the inability to use
metric-driven standards to comprehensively examine and improve
how the VA was using its resources to deliver health care.
We often hear, ``When you have seen one VA, you have seen
one VA,'' and that stands to reason in many ways. But every
time I sat where you sit now and ask VHA's past leadership if
they were able to provide metrics on health care delivered for
resources expended, I wasn't able to get an answer. I was told
the numbers existed, but they never seemed to materialize. And
some would say, ``Well, it costs more to do this, it costs more
to do that,'' but they really had no metric of explaining how.
The goal, I think, for our VA health care system should be
to deliver quality care efficiently in a timely fashion. If you
are determined to deliver health care to all of those veterans
that are eligible for care in a timely fashion, you want to
make sure that you can be the most efficient.
So my legislation, H.R. 6066, seeks to ensure that actual
data, based on the measure of relative value units, will ensure
we can best serve our veterans.
What is a relative value unit? It is something assigned.
CMS uses it. And it gives us a value to what procedure you have
just performed or what function you just performed. There are
more RVUs for an open heart surgery than there is for an
incision and drainage of an abscess, as you might imagine.
So recently the VA began tracking productivity metrics
across more than 30 specialties, but significant gaps still
exist and persist in the effectiveness and completeness of the
current reporting.
Last year a GAO report that is cited in my written
testimony found that current VA productivity metrics, including
RVUs, called RVUs, are not complete and may not be accurate.
Clinical specialties are siloed, certain patient work is not
measured, and contract providers go unmeasured. So the data
that we have is not really useful because it is not complete.
And recording an RVU and scoring an RVU when you perform a
procedure is very simple. You have certain procedures in your
specialty that you do every day, and you document it in your
note, and you can just simply point out, ``I did this and I did
that.'' And then that can be scored.
So this is legislation to tackle the GAO's recommendations
by tracking RVUs across all providers and providing more
comprehensive and systematic review to put the data to work,
and by doing this accurately we can figure some things out. In
the private sector, obviously, the more RVUs you produce, the
more you get paid. It is different in the VA. You are paid the
same anyway.
But what we want to do is measure productivity. If you have
two practitioners operating at the same time, doing the same
type of work, and one is producing twice as much as the other,
you can evaluate that by knowing how many RVUs you produced.
So what do you do with that? In our practice if we saw it
we would say, you know, well, this doctor has a physician
assistant or two medical assistants as opposed to your one, and
if we do that we can increase the productivity. That doesn't
decrease doctor time. It actually will increase doctor time
with patients.
So these are things that I want to bring to light. It also
can affect how you are scheduling. You can learn so much. You
may need to know that you need one more treatment room to be
more efficient.
So this is an adequate way of really determining how
productive someone is or a clinic is or a hospital is and can
guide us on where we may need to make changes to be more
effective.
Last year, working with the Committee, we drafted the
language found in the bill in response to the May 2017 GAO
report and recommendations and from years of observation from
the dais where you now sit. This language was included in H.R.
4242 when it passed out of this very Committee last November,
though it did not make it into the final VA MISSION Act. That
is why I am introducing this language as a standalone bill.
The VA, like all government agencies, is operating in a
resource-constrained environment. It is our obligation to make
sure that the resources we do have are directed at the veterans
that need care. If we can't measure this we can't improve it.
None of us can claim to have a monopoly on good ideas. So I
stand ready work with all interested parties to make sure that
every dollar we spend within the Veterans Health Administration
is being used to effectively deliver care to our veterans.
Thank you, and I yield back.
[The prepared statement of Brad R. Wenstrup appears in the
Appendix]
Mr. Dunn. Thank you very much, Dr. Wenstrup.
I now recognize Captain Clay Higgins from Louisiana for 5
minutes.
STATEMENT OF THE HONORABLE CLAY HIGGINS
Mr. Higgins. Thank you, sir.
Chairman Dunn, Ranking Member Brownley, thank you for
considering H.R. 5693, the Long-Term Care Veterans Choice Act.
My bill, H.R. 5693, authorizes the Department of Veterans
Affairs for 3 years to cover the cost of long-term care at
medical foster homes for up to 900 veterans otherwise eligible
for nursing home care through the VA.
Medical foster homes are private homes in which a caregiver
provides services to a small group of individuals who are
unable to live without day-to-day assistance, and are an
alternative to nursing homes for those who require nursing home
care but prefer a noninstitutional setting with fewer
residents.
For many young veterans in need of round-the-clock care,
medical foster homes can provide a more age-appropriate,
independent setting than traditional nursing homes.
The U.S. Department of Veterans Affairs has run its medical
foster home initiative since the year 2000, and today VHA
oversees more than 700 licensed caregivers caring for nearly
1,000 veterans in 42 States.
To be eligible to provide care for veterans, a VA medical
foster home provider must provide a background check, complete
80 hours of initial training and 20 hours annually afterwards,
and cannot work outside of the home.
Unfortunately, while the VA will cover the cost of home-
based primary care for eligible veterans living in medical
foster homes, the VA does not cover the cost of medical foster
home living arrangements for veterans otherwise eligible for
nursing home care through the VA. Instead, these veterans must
pay for medical foster home services out of pocket or through
private insurance.
Costs associated with medical foster home services range
between $1,500 and $3,000 a month, which is significantly lower
than the nearly $7,000 per month the VA might otherwise pay per
patient at a State VA nursing home.
In my home State of Louisiana, the VA operates state-of-
the-art veterans' homes that provide residents a high quality
of care in an understanding, supportive environment. This is
understood. In my district I have toured and visited the
Southwest Louisiana Veterans Home in Jennings, Louisiana, and I
can personally attest to the high quality of care and sense of
well-being among veterans there.
But much like in the civilian world, there is no one-size-
fits-all standard of care for veterans. Veterans should be
afforded flexibility to use the benefits they righteously
earned and that best suits their own individual needs. H.R.
5693, the Long-Term Care Veterans Choice Act, gives much-needed
choice and personal dignity back to these brave men and women
who have selflessly sacrificed for our Nation.
I look forward to the support of my colleagues on this
bill.
Mr. Chairman, Madam Ranking Member, thank you for allowing
me to speak on this bill, and I yield the balance of my time.
[The prepared statement of Clay Higgins appears in the
Appendix]
Mr. Dunn. Thank you very much, Representative Higgins.
I now recognize former U.S. Marine Representative Mike Bost
from Illinois for 5 minutes.
STATEMENT OF THE HONORABLE MIKE BOST
Mr. Bost. Thank you, Chairman Dunn and Ranking Member
Brownley, for providing me the opportunity to testify before
the Subcommittee on Health on my legislation, H.R. 5864, the VA
Hospitals Establishing Leadership Performance Act, or VA HELP
Act.
The mission of the Department of Veterans Affairs is to
care for those who shall have borne the battle. When our heroes
transition from the military they deserve to have access to
quality health care and service.
Unfortunately, the VA continues to fall short on that
promise due in part to failures in human resource management
and operations. VA's internal assessment and those by the
Government Accountability Office and VA inspector general have
identified serious human capital challenges and weaknesses
within the VHA's human resources operations.
Most recently, we all heard about the inadequate staffing
and human resources management deficiencies that contributed to
the failures at the Washington, D.C., VA Medical Center.
This issue hits very close to home for me after the VA
National Center for Patient Safety surveyed the Marion VA
Medical Center. The Marion VA's Patient Safety Culture Survey
showed a considerable decline in key factors, such as
communications between management and staff and the frequency
of reporting problems to management.
During the site visit, multiple employees raised concerns
about poor management and poor communications, distrust between
leadership and management, and the lack of accountability.
These factors helped measure the culture at the VA
facility, and it was clear that the employees were unsatisfied
with their work environment.
Following this report, General Bergman and I sent a letter
to then-Secretary Shulkin requesting that the VA further
investigate this matter. The effort was followed up by an
Oversight and Investigations Subcommittee staff visit to the
Marion VA Medical Center in order to get a firsthand look at
the issues at the facility.
A report of the Subcommittee's findings confirmed a lack of
accountability, improper communication, and a lack of standards
to measure the success of the H.R. department. We also learned
that there are limited education qualifications required to be
chief of human resources in the VA.
I do not know of any health system that has a chief of HR
without a college degree overseeing thousands of employees and
responsible for negotiating job offers and proposing
disciplinary action. I also do not know of any health care
system that would hire or promote an individual to manage and
oversee a human resources department without requiring a
college degree.
During my time on the Committee, I have seen that it is
common in the VA to move problem employees into higher-level
jobs, with greater responsibility, without assessing their
prior leadership experience and performance.
Unfortunately, despite the Subcommittee's findings and
several efforts to encourage the VA headquarters leadership to
address these problems, limited actions have been taken. My
office continues to receive complaints about the mistrust of
the medical center leadership, confusion and inconsistencies in
its disciplinary process, and failures to track employee
performances and outcomes.
Human resources management is a critical part of delivering
quality health care. HR is responsible for recruiting and
retaining highly qualified personnel and professionals, and the
current status quo within the VHA's HR offices cannot continue.
H.R. 5864, the VA HELP Act, will ensure that the VA
addresses deficiencies within its human resources department by
giving it the ability to compare the performance of the
departments across the VHA and to measure their successes.
This straightforward legislation instructs the Secretary of
the VA to establish qualifications for human resources
positions within the Veterans Health Administration. It also
requires the VA to establish standardized performance metrics
for human resources positions.
These commonsense reforms will ensure that the human
resources departments at the VA medical centers are operating
on a uniform standard and that it is clear who qualifies to
hold such important positions.
In closing, I would like to thank Representative Sinema for
her helping to introduce this legislation, and would like to
thank you, Mr. Chairman and Ranking Member Brownley, for
allowing me to testify before the Subcommittee. I hope that we
can work together on H.R. 5864 to ensure that our Nation's
veterans are being provided for with the best possible care
from our VA employees.
And with that, Mr. Chairman, I yield back.
[The prepared statement of Mike Bost appears in the
Appendix]
Mr. Dunn. Thank you, Representative Bost.
I now recognize for 5 minutes Congresswoman Jenniffer
Gonzalez-Colon.
STATEMENT OF THE HONORABLE JENNIFFER GONZELEZ-COLON
Miss Gonzalez-Colon. Thank you, Chairman Dunn and Ranking
Member Brownley, for having this hearing today, and all Members
here. And thank you for including H.R. 5938, the Veterans
Serving Veterans Act, as part of the agenda for this afternoon.
As previously stated on several occasions before this
Committee, the Department of Veterans Affairs suffers chronic
staffing challenges that complicate the delivery of proper and
timely care. These challenges are often exacerbated by a time-
consuming hiring process.
The VA facilities within my district are no exception to
that. As a matter of fact, this issue never fails to come up
during meetings with veterans in Puerto Rico.
Therefore, as an effort to identify a remedial option, my
bill seeks to amendment Section 208 of the Choice and Quality
Employment Act of 2017 to include military occupational
specialties of soon-to-be-discharged servicemembers that
correspond to vacant positions in the VA in the recruiting
database, as well as servicemembers' contact information and
the date of discharge.
Employment after separating from the military is beneficial
for veterans from a psychological and financial perspective.
My bill would require the VA to first coordinate with the
Department of Defense to identify soon-to-be-separated
servicemembers with military occupational specialties needed by
Veterans Affairs and obtain their date of separation and basic
contact information.
Second, to maintain a database searchable by VA personnel
for purposes of hiring soon-to-be-separated servicemembers.
And third, implement direct hiring and appointment
procedures for vacant positions listed on the database for
servicemembers who apply for these positions.
Another objective of this bill will require the VA to
implement a program to train and certify former DoD health care
technicians as intermediate care technicians, or ICTs, and to
address the large demand for health care providers at the
Veterans Health Administration.
Currently, these very skilled technicians, trained by the
Department of Defense at significant taxpayer expense, have
difficulty gaining employment in their field after separating
from the Armed Forces due to the lack of a certification. At
the same time, the Veterans Health Administration has
significant shortages of providers.
VHA instituted the Intermediate Care Technician Pilot
Program in 2013 to train and utilize ICTs at the VA facilities
in a variety of roles. The program has since then received
remarkable satisfaction rates and helped fill a void of medical
providers.
Implementing a program to train and certify eligible
veterans to work as ICTs will help formalize the process, as
well as provide for continued program support and expansion,
ensure rigor in curriculum development, competency assessment,
program monitoring, and allow the pool of eligible ICTs to
continue growing to meet veterans' health care needs.
Mr. Chairman and Members of this Committee, it is important
to keep in mind that servicemembers are a remarkable asset upon
transitioning from military service. This bill seeks to further
close the gap between transitioning members and the VA by
helping them occupy positions currently in demand and provides
an opportunity for greater access to medical care. Moreover, it
allows for veterans to be cared for by fellow veterans in ways
that are most needed by the VA.
As a former State legislator in Puerto Rico, I am aware
that no bill is set in stone, and legislation is often the
product of several reviews and revisions, and I look forward to
receiving the feedback of this panel and welcome any comments
or suggestions on ways that we can move this forward. But I
want to thank the people from the American Legion and the
Disabled American Veterans and the Military Officers
Association of America for their support for this bill.
With that, I yield the balance of my time.
[The prepared statement of Jenniffer Gonzalez-Colon appears
in the Appendix]
Mr. Dunn. Thank you, Representative Gonzalez-Colon.
I will now recognize former United States Air Force veteran
Representative Jeff Denham from California for 5 minutes.
You are recognized.
STATEMENT OF THE HONORABLE JEFF DENHAM
Mr. Denham. Thank you, Mr. Chairman. It is good to be back
with the Committee that I spent a number of years on, as well,
fighting for America's veterans. Thank you for this opportunity
to speak on H.R. 5974, the VA COST SAVINGS Enhancement Act. I
introduced this bipartisan bill to improve care for our
veterans and ensure we are using the latest cost-saving
technology.
Specifically, this deals with VA medical waste in
facilities across the entire country, resulting in huge savings
within the next 5 years. System-wide, this will save the VA
millions of dollars each year and directly improve safety and
health care for our veterans.
The medical waste, known as red bag or biohazardous waste,
is infectious waste produced at VA facilities and hospitals.
Since this waste is contaminated by bloody and bodily fluids it
poses a risk of transmitting an infection and has to be handled
in a special way.
If a VA facility was doing this on-site sterilization
through these large machines, this waste can be not only
disinfected immediately, but also avoiding costly off-site
movements. Meaning that this waste, which can't be compacted,
fills trucks very, very quickly, ends up with a lot of trucks
on the road. And as we have seen from other national disasters,
this infectious waste could end up in the wrong areas within
our community.
So handling it on-site is not only a huge cost savings, but
handling it on-site is also much safer for our veterans, as
well as the communities that this would normally be trucked
through.
On the cost side, currently technologies can treat waste
for 7 to 9 cents per pound compared to 30 to 60 cents off-site.
So again, we are wasting millions of dollars each year shipping
this infectious waste around the country. This bill stops that.
The VA recognizes the benefits of this technology, and
approximately 20 percent of the VA facilities already have
these machines on-site, but, unfortunately, they have been very
slow in expanding these across the country.
In 2016 the MilCon-VA appropriations bill acknowledged the
huge cost savings, as well as the beneficial environmental
impacts and the energy savings associated with on-site medical
waste treatment. The VA developed a blanket purchase agreement
to streamline the purchasing of these machines, but,
unfortunately, again implementation has been very slow.
It is time to realize the full benefits of this technology
and bring the VA into the 21st century. Our veterans deserve
the highest quality of care we can provide. And this technology
improves the crisis readiness and is safer, more efficient,
more cost effective and environmentally friendly than
traditional medical waste disposal.
Installing these machines immediately can begin the savings
of millions of dollars for the VA and directly improve our care
for our veterans.
I urge my colleagues to support this policy.
[The prepared statement of Jeff Denham appears in the
Appendix]
Mr. Dunn. Thank you very much, Representative Denham.
Once again, I thank all of you for being here and for
sponsoring these bills on our agenda this afternoon. The first
panel is now excused. I will pause while the members of the
second panel settle themselves here at the table.
Mr. Dunn. I will now welcome the second panel to the
witness table. Joining us on the second panel is first Mr.
Roscoe Butler, the deputy director for health care, veterans
affairs and rehabilitation for the American Legion; Jeremy
Villanueva, the associate national legislative director for
Disabled American Veterans; Kayda Keleher, the associate
director for national legislative service for the Veterans of
Foreign Wars of the United States; and Ms. Jessica Bonjorni,
acting assistant deputy Under Secretary for health for
workforce services for the Veterans Health Administration of
the U.S. Department of Veterans Affairs. And joining Ms.
Bonjorni is Dayna Cooper, the director of home and community-
based programs for the Veterans Health Administration.
We will begin this afternoon with Mr. Butler.
You are now recognized for 5 minutes.
STATEMENT OF ROSCOE BUTLER
Mr. Butler. Thank you.
According to a March 2017 study commissioned by the
Association of American Medical Colleges, there will be a
shortage of more than 100,000 doctors by 2030. According to a
September 2017 VA OIG report, the largest staffing shortages in
the Veterans Health Administration were medical officers,
nurses, psychologists, physician assistants, and medical
technologists.
Many of the bills being discussed today are designed to
address the VHA staffing crisis, and the American Legion thanks
this Subcommittee for holding this important hearing.
Good afternoon, Chairman Dunn, Ranking Member Brownley, and
distinguished Members of the Subcommittee on Health. On behalf
of the national commander, Denise H. Rohan, and the American
Legion, the country's largest patriotic wartime veterans
service organization, comprising over two million members and
serving every man and woman who has worn the uniform for this
country, we thank you for the opportunity to testify on behalf
of the American Legion's position on the following pending and
draft legislation.
H.R. 2787, the Veterans-Specific Education for Tomorrow's
Medical Doctors Act. This bill will establish a pilot clinical
observation program within the Department of Veterans Affairs
for premed students preparing to attend medical school.
The American Legion is deeply troubled by staffing
shortages within the Department of Veterans Affairs,
particularly within the Veterans Health Administration, and has
consistently voiced concerns since the inception of our System
Worth Saving Program in 2003.
The American Legion has identified and reported staffing
shortages at every VA medical center and reported these
critical deficiencies to Congress, VA's central office, and the
President of the United States. The American Legion believes
this bill will make a difference and supports H.R. 2787.
H.R. 3696, the Wounded Warrior Workforce Enhancement Act.
The American Legion believes, due to the shortage of physicians
in critical specialized areas, such as orthotics and
prosthetics, Congress must ensure resources and funding are
available to support continuing education and training of such
physicians.
We know as the number of veterans needing orthotics and
prosthetic services increases there will be a continuing need
for clinicians at the master's degree level to meet this
increasing demand. For this reason, the American Legion
supports H.R. 3696.
H.R. 5521, the VA Hiring Enhancement Act. The American
Legion has long expressed concerns about staffing shortages at
Department of Veterans Affairs Veterans Health Administration
medical facilities, to include physicians and medical
specialist staffing.
We, the American Legion, believe the VA Hiring Enhancement
Act will help ensure when a qualified physician who is an
applicant for an appointment to a position in the Veterans
Health Administration has entered into a covenant not to
compete with a non-department facility, the individual will not
be barred from accepting an appointment to a position in the
Veterans Health Administration.
The American Legion believes enforcing noncompete
agreements to VA hires is overly broad and should be
unenforceable under public policy. Traditional reasons behind
noncompete agreements to bar competitive advantages to protect
sensitive information simply do not exist in this context. For
this reason, the American Legion supports 5521.
The American Legion also supports H.R. 5693, the Long-Term
Care Veterans Choice Act, and H.R. 5938, the Veterans Serving
Veterans Act of 2018.
However, the American Legion does not have an official
position on H.R. 5864; the VA COST SAVINGS Enhancement Act; and
the draft bill to improve the productivity of the management of
Department of Veterans Affairs health care, and for other
purposes.
In conclusion, the American Legion thanks this Subcommittee
for the opportunity to voice the position of the over two
million veteran members of this organization, and I am
available to answer any questions that you and the Subcommittee
may have.
[The prepared statement of Roscoe Butler appears in the
Appendix]
Mr. Dunn. Thank you very much, Mr. Butler.
Mr. Villanueva, you are now recognized for 5 minutes.
STATEMENT OF JEREMY VILLANUEVA
Mr. Villanueva. Thank you. Chairman Dunn, Ranking Member
Brownley, and Members of the Subcommittee, thank you for
inviting DAV to testify at this legislative hearing of the
Subcommittee on Health.
DAV, a nonprofit veterans service organization comprised of
over one million wartime service-disabled veterans, is
dedicated to a single purpose: empowering veterans to lead high
quality lives with respect and dignity. As a service-disabled
veteran myself and one who uses the VA health care system, I am
pleased to be here to present DAV's views on the bills under
consideration by the Subcommittee.
H.R. 5521, the VA Hiring Enhancement Act, would render
noncompete agreements between an applicant for VA employment
and a previous employer nonapplicable with regard to VA
employment. Employees appointed with this understanding would
be required to serve at least 1 year in their position or the
remainder of their noncompete agreement, whichever is longer.
The bill would also authorize VA to hire on a contingency
basis physicians completing residencies not later than 2 years
after appointment. If the contingent employee has not satisfied
VA requirements for the position in that time, that individual
will not be appointed to the position.
DAV supports efforts to recruit, retain, and develop a
skilled clinical workforce to need the needs of veterans. We
thereby share the goal of this legislation in creating as large
as possible an applicant pool for qualified medical
professionals to treat our service-disabled veterans in the VA.
DAV Resolution No. 228 calls for effective recruitment,
retention, and development of the VA health care workforce.
Because this measure attempts to reduce barriers for the VA to
hire physicians, we support the intent of this bill.
We thank the Subcommittee for considering H.R. 5693, the
Long-Term Care Veterans Choice Act, that would improve VA's
medical foster home program.
Medical foster homes enable those veterans with serious
chronic conditions that meet nursing home level of care to
remain in a residential environment instead of being
institutionalized. Participation in this program is voluntary,
and veteran residents have reported very high satisfaction
ratings.
Currently, veterans who wish to reside in a medical foster
home but are unable to pay the approximately $1,500 to $3,000
per month are not able to utilize this program, so many are
placed in nursing homes at much greater cost to the VA.
Moreover, VA would pay more than twice as much for nursing home
care than if the VA was granted this bill's proposed authority
to pay for VA medical foster homes.
Mr. Chairman, we must be fully cognizant of our aging
veteran population's need for programs such as this. DAV's
Resolution No. 227 calls for legislation that increases access
and improves long-term services and supports for service-
connected disabled veterans.
To allow a veteran to stay in their community while
receiving the best quality of care and maintaining a semblance
of independence would in some small way show this Nation's
gratitude to those who have sacrificed for it. DAV strongly
supports this legislation and calls for swift passage.
H.R. 5864, the VA Hospitals Establishing Leadership
Performance Act, would establish qualifications for each human
resource position with the VHA, establish standardized
performance metrics for each such position, and submit to
Congress a report that details the actions taken.
The VA has long needed improvement in the performance of
their human resources staff. This has been noted by
organizations such as the Commission on Care and the GAO. Each
organization has indicated that administration-wide improvement
requires systemic changes that would fundamentally alter the
operations, leadership, and guidance of the current human
capital management system.
We believe that H.R. 5864 offers a good starting point for
the fundamental overhaul of VA's human capital management
system, but it is only a start. VA also needs to look at
streamlining and simplifying its recruitment and hiring
practices. It needs to look at different programs and practices
for staff retention, development, employment benefits, and
performance management to maximize employee engagement.
Most importantly, human capital management reform will
require a long-term commitment from VA's leadership and
Congress. However, the intent of H.R. 5864 will likely not be
fully realized if VA is incapable of hiring or developing the
human talent necessary to fill these positions.
DAV supports this legislation, in accordance with DAV
Resolution No. 228, which calls for a simple-to-administer
alternative VHA personnel system in law and regulation which
governs all VHA employees, applies best practices from the
private sector to human capital management, and supports pay
and benefits that are competitive with the private sector; and
Resolution No. 221, which supports VA's use of meaningful and
clearly articulated measures to gauge employees' performance.
Mr. Chairman, this concludes my testimony, and I would be
pleased to address any questions related to the bills discussed
today.
[The prepared statement of Jeremy Villanueva appears in the
Appendix]
Mr. Dunn. Thank you, Mr. Villanueva.
Ms. Keleher, you are now recognized for 5 minutes.
STATEMENT OF KAYDA KELEHER
Ms. Keleher. Chairman Dunn, Ranking Member Brownley, and
Members of the Subcommittee, it is my honor to represent the
women and men of the VFW and our Auxiliary.
The VFW agrees with the intent of the Wounded Warrior
Workforce Enhancement Act, but it has some serious concerns
which prevent our organization from providing support at this
time.
One of VA's four statutory missions is to educate and train
health professionals to enhance the quality of care provided to
patients within VA. VA accomplishes this through coordinated
programs and partnerships with affiliated academic
institutions.
Section 2 of this legislation would require VA to provide
grants to orthotics and prosthetics graduate programs which are
accredited by the National Commission on Orthopedic and
Prosthetic Education in cooperation with the Commission on
Accreditation of Allied Health Education Programs. These grants
would be eligible for use at the selected institutions to
expand sites, build infrastructure, supplement salaries,
provide financial aid, or purchase equipment.
While providing this in such ways, these grants could be of
value to VA and VA patients, but the VFW does not believe this
legislation would be of value in the way it is currently
written. This is because the grants may be paid to institutions
without any tie to VA.
Priority for grant recipients would go to institutions
partnered with VA, but is not a requirement. For institutions
applying for the program they must show a willingness to
participate with VA, but, again, they are not required to
actually participate.
The VFW believes for these institutions to receive these
grants they must agree to some level of partnership and
participation with VA.
Section 3 of this legislation would provide a larger grant
to one institution to become a center of excellence for
orthotics and prosthetics. VA and DoD already have these
facilities, which provide those best practices to veterans.
This grant would also not require any form of partnership or
participation from these institutions with VA.
The VFW cannot justify outsourcing valuable VA resources to
bolster a non- VA entity that would not benefit veterans.
The VFW is pleased the VA Hiring Enhancement Act would
remove noncompete contracts for providers who want to work for
VA and supports removing this barrier to employment, though the
VFW cannot support the remaining provisions within Section 3,
which would limit VA's hiring pool for health care providers as
well as duplicate current law providing VA the authority to
make job offers to current residents.
We are all aware that VA currently has 38,000 job
vacancies. These vacancies must be significantly reduced before
the VFW feels more restrictions may be put upon VA regarding
who the agency may hire. To address quality of care, which VFW
members prefer from VA, we must address access to care.
The VFW agrees with the intent of the Veterans Serving
Veterans Act of 2018, but has concerns with the legislation as
it is currently written.
This legislation would establish a database worked on by
DoD and VA, and this technology would withhold information of
individuals currently serving in the military with job
positions which are needed within VA.
Servicemembers wanting to opt out of this database and
having their personally identifiable information shared with an
array of VA employees would be required to submit a letter.
This database would then be used by VA to recruit potential
employees for DoD before they exit from service.
Aside from our concerns over the access to this personal
information, the VFW believes these servicemembers should have
to opt into the database, and that they would also still be
subjected to experiencing bureaucratic difficulties while
switching from DoD to VA.
The VFW agrees that DoD and VA need to work together to
identify medical professionals currently serving who are
interested in coming over to VA and that these individuals need
to have their credentials streamlined so that the day they
receive their DD 214 in hand they can walk into their new
office at VA.
The VFW agrees with the intent of the draft legislation to
improve productivity of the management of VA health care, but
has some concerns with it as currently written.
RVUs are used as a national standard for determining budget
expenses, cost benchmarks, and productivity within the private
sector. They are primarily used in the private sector to
determine provider payments, something that is not an issue for
VA providers on a government salary.
The VFW believes there is a value to tracking RVUs within
VA, and our organization also believes that as funding
increased, and hopefully continues to increase, that the RVUs
would show an increase in productivity.
With that said, the private sector is not required to
publicly report most data that VA is required to publicly
report, and that includes RVUs. While this legislation would
take into account nonclinical duties, the VFW is concerned
about more double standards possibly being held to VA.
Chairman Dunn, Ranking Member Brownley, and Members of the
Subcommittee, this concludes my testimony. Thank you again for
the opportunity to represent the Nation's largest combat
veteran's organization, and I look forward to taking your
questions.
[The prepared statement of Kayda Keleher appears in the
Appendix]
Mr. Dunn. Thank you, Ms. Keleher.
Ms. Bonjorni, you are now recognized for 5 minutes.
STATEMENT OF JESSICA BONJORNI
Ms. Bonjorni. Good afternoon, Chairman Dunn, Ranking Member
Brownley, and Members of the Subcommittee. I am accompanied
today by Ms. Dayna Cooper, director of home and community care
from the Office of Geriatrics and Extended Care. We appreciate
the opportunity to discuss VA's views on pending health care
legislation, much of which is aimed at bolstering VA's critical
workforce management programs.
There is one bill, the draft VA COST SAVINGS Enhancement
Act, for which we are unable to provide views at this time
because it came late to the agenda, but we will follow up with
the Committee as soon as possible.
Chairman Dunn, we appreciate the Committee's focus on the
topic of human resources as a key to filling the Department's
mission of serving veterans. We are grateful for the human
capital authorities extended to the VA in the recently passed
VA MISSION Act and in last year's VA Choice and Quality
Employment Act.
As just one example of how those new laws have helped VA,
we have recently developed a joint program with the Department
of Defense called the Military Transition and Training
Advancement Course, which is an entry-level program that allows
transitioning servicemembers to be trained in occupations
before they separate and then make a seamless transition into
the VA. We are trying this right now in the national capital
region.
In the interest of being brief, I will highlight a few
points regarding the bills on the agenda today, and of course
our written testimony provides further details.
VA supports the intent of H.R. 2787, the VET MD Act, to
develop a clinical observation pilot program within VA for
premedical undergraduate students to shadow physicians.
However, we do note in our testimony concerns about high
unfunded costs, implementation challenges, and suggestions for
improvements.
VA continues to recommend providing clinical observation
opportunities for all pre-health occupation students, rather
than focusing exclusively on premedical students. In addition,
VA recommends including both undergraduate and
postbaccalaureate students, since these students have displayed
interest in pursuing health careers.
We would be glad to discuss further with the Committee how
we believe the bill can be improved.
H.R. 3696, the Wounded Warrior Workforce Enhancement Act,
calls for establishing a new or expanding existing prosthetic
or orthopedic graduate programs and the establishment of one
prosthetic/orthotic research center of excellence.
VA does not support this bill because we believe VA already
fulfills the intent, using interdisciplinary teams that provide
rehabilitation services to veterans' unique needs. VA offers
these in-house services at 84 laboratories across VA. In
addition, VA contracts with more than 600 specialized vendors.
Through both in-house staffing and contractual
arrangements, VA is able to provide state-of-the-art,
commercially available items ranging from advanced myoelectric
prosthetic arms to specific custom-fitted orthoses.
H.R. 5521, the VA Hiring Enhancement Act, would give VA
additional tools in the hiring of title 38 employees, and in
particular physicians.
Noncomplete clauses often prevent VA from freely hiring
physicians from the local medical community. Exempting VA from
these restrictive and nonapplicable covenants would prove
beneficial. VA would hope to restrict this section to
physicians hired under 7401(1) of this title.
Section 3 of the bill would permit VHA to make a contingent
appointment as a VHA physician on the basis of a physician
completing their physician residency training. VA endorses
Sections 1 and 2 of this bill, however, has concerns with
Section 3 and requests the opportunity to discuss with the
Committee.
We appreciate the vision and compassion outlined in H.R.
5693, the Long-Term Care Veterans Choice Act, which will help
VA meet the escalating demand for nursing home care, which is
projected to double over the next decade for Priority 1A
veterans, while also providing veterans a choice.
VA covers 100 percent of their nursing home costs. However,
if these veterans with highly service-connected conditions
would prefer to receive their care in a VA medical foster home
they must pay out of pocket at an average cost of $2,400 per
month because VA does not currently have the authority to pay.
This bill will help VA meet this increasing demand for
nursing home care by offering the option of a VA-approved
medical foster home while simultaneously reducing the need to
build more nursing homes or double VA's nursing home
expenditures.
H.R. 5864, VA HELP Act, proposes to standardize
qualification requirements and performance metrics for human
resources positions.
VA does not support the intent of this bill, but does
support efforts to professionalize the H.R. function throughout
government.
Creating VA-specific standards would negatively impact VA's
ability to retain current staff or recruit H.R. professionals
from other Federal agencies. VA is currently developing
standardized performance metrics for HR specialists to be
implemented in fiscal year 2019.
If a decision is made to proceed with the bill, VA requests
the opportunity to meet with the Committee to propose revisions
of language to address our concerns.
Regarding the draft Veterans Serving Veterans Act of 2018,
VA supports the intent of this bill. However, we believe VA is
able to accomplish the content of this bill with existing
authorities.
Efforts are already underway to target transitioning
military members for mission-critical and difficult-to-fill
positions by using data contained in a VADIR database that
already exists. The resource has resulted in a recruitment
pipeline that will now allow VA to reach out directly to
transitioning servicemembers.
Finally, the draft bill to improve the productivity of VA
health care calls for VA to track relative value unit
production standards and includes other associated
requirements.
VA does not support the bill as we already track RVUs for
licensed independent providers, and performance standards and
productivity targets are established with annual reviews
currently in place at a minimum.
VA has significant concerns about the mandatory training
required in the bill, which would take providers away from
providing direct patient care. VA would like to discuss this
bill with the Committee.
Mr. Chairman, this concludes my testimony. My colleagues
and I are prepared to answer questions.
[The prepared statement of Jessica Bonjorni appears in the
Appendix]
Mr. Dunn. Thank you, Ms. Bonjorni.
And I thank the entire panel for being here. We will move
to the questioning portion of the panel now.
I do want to make mention that votes may have been moved
up, maybe as early as 4:15, so I am going ask the Members of
the panel to make their questions succinct to give the panel
witnesses maximum time to answer. And I am also going to ask
the witnesses on the panel to try to be concise in your answers
so that we can get as many questions in as we possibly can.
I now yield myself 5 minutes.
I will start with Ms. Bonjorni and Ms. Cooper. Many of the
bills on today's agenda have financial scores that will require
offsets before they can potentially move to the floor. Will you
commit to working with the Subcommittee to find offsets within
our jurisdiction for the proposals that you support?
Ms. Bonjorni. Yes, we will.
Mr. Dunn. Excellent.
Again, Ms. Bonjorni, when do you expect to have a cost
estimate for H.R. 5521, the VA Hiring Enhancement Act,
available for us to look at?
Ms. Bonjorni. I believe we will be able to have that within
the next 2 weeks, if not sooner.
Mr. Dunn. Okay. Excellent. We will be looking for that.
Ms. Bonjorni, your opposition to Section 3, H.R. 5521, the
Hiring Enhancement Act, is based on the fact that you think the
VA already has rules requiring completion of residency. The
wording of that is such that it is residency or its equivalent.
What is the equivalent to completion of a residency in VA
standards?
Ms. Bonjorni. The equivalent is something that is
determined by the professional standards board to have met the
intention of a residency program. It is extremely rare for us
to hire people who have not gone through a residency program.
Mr. Dunn. Would not it be more transparent and easier to
simply require the staff physician, in order to be a staff
physician in a VA facility, you have to complete residency
training, just say that outright?
Ms. Bonjorni. It may be.
Mr. Dunn. All right. We think it might be, too.
Ms. Keleher, your opposition to Section 3, H.R. 5521, was
that you thought it might be duplicative of current law. We
looked at that same law. We thought that it did not apply to
physicians, but rather other professionals in the VA. Do you
interpret that law differently than we do?
Ms. Keleher. Yes, Mr. Chairman, we do.
Mr. Dunn. You feel pretty confident in that?
Ms. Keleher. Yes, sir.
Mr. Dunn. All right. Well, let's talk about that.
Ms. Bonjorni, how many more veterans do you think would
elect to receive--let me change the order of these questions.
How many of the veterans currently in medical foster homes
would otherwise be entitled to VA-paid nursing home care?
Ms. Bonjorni. I am going to defer that question to Ms.
Cooper.
Mr. Dunn. Excellent.
Ms. Cooper. Currently, there are just under 300 veterans in
medical foster homes that are paying for their care that would
be eligible to receive the payment under this bill. There are
approximately 15,000 Priority 1A veterans that are receiving
care in a nursing home. We anticipate that there would be
approximately 5,000 of those that would down the road be
choosing a medical foster home.
Mr. Dunn. So you anticipate a future demand of
approximately 5,000 veterans--
Ms. Cooper. Based on our current--
Mr. Dunn [continued].--if we were to open this up?
Ms. Cooper. Correct.
Mr. Dunn. All right. Well, that answered my next question.
And I think I will be careful with the Committee's time,
and I will yield now to Ms. Brownley, the Ranking Member.
Ms. Brownley. Thank you, Mr. Chairman.
I wanted to talk a little bit about H.R. 6066.
So, Mr. Villanueva, could you talk to me a little bit
about--I know you have already said something about this
particular bill--but with regards to how your membership feels
and sort of trying to outline for the Committee some of the
differences between VA delivery of health care and productivity
and private providers?
Mr. Villanueva. Thank you for that.
Ms. Brownley. This is the RFUs measurement for
productivity.
Mr. Villanueva. Right, right. And thank you for that
question. It is indeed my pleasure to answer that.
Essentially, we don't have a position on this bill as of
yet. We do believe that there are still some clarifications
that need to be made, specifically what exactly these RVUs
would be used for, how they would receive them from the private
care community, and how they would be comparing them.
Because we do believe that with the VA being a capitation
system and the private care community not, that it would be
essentially, like I believe one of my colleagues at this table
has said, be tantamount to comparing apples to oranges.
Ms. Brownley. And, Ms. Keleher, do you have any comments
relative--
Ms. Keleher. Yes, thank you.
As my colleague next to me has stated, we do have concerns
with the apples-to-oranges comparison. I think everybody has
kind of beat it over the head here with VA, and their
productivity varies compared to the private sector not just
based on income, but also on quality of care.
VFW has conducted multiple, multiple surveys in recent
years and we get consistent feedback from our members.
Some quotes. We have a World War II veteran from Florida
who said, ``VA doctors listen to me and take time to explain
the answers to my questions.'' Or we have others who say,
``They treat me like a hero and give me the time that I
actually need.'' That was a Vietnam veteran.
With that said, the number three problem that our members
say they face when using non-VA care is actually timeliness,
and they feel rushed with their providers. So we don't want
that to be an unintended negative outcome.
Ms. Brownley. I think in some way we are going to have to
figure out how to measure productivity, but also putting a
value on the fact that doctors, medical professionals within
the VA spend time with veterans to answer their questions. We
are asking more and more for doctors to screen for various
other things that they might not have an appointment for.
And I think we place a value on that. But somehow
understanding that we are placing a value on that, but also
being able to properly measure our efficiencies and
productivities as well. So somehow, some way, we are going to
have to figure that one out.
Mr. Higgins, by the way, I like your bill. I think it is a
good bill.
Mr. Higgins. Thank you, ma'am.
Ms. Brownley. And to Mr. Butler, so is this a bill that is
important to your membership? And I think it is, but if you
would express to us why.
Mr. Butler. The medical foster home?
Ms. Brownley. Yes.
Mr. Butler. Currently right now VA is not eligible to pay
for care for veterans. They just refer veterans to a foster
home. So any veteran who is eligible for nursing home care,
this bill gives VA the authority to pay for their care in
medical foster homes, which could result in a significant cost
savings to the VA and the government.
So we fully support the bill because we believe that any
money saved is a benefit to our Nation's veterans and the
American taxpayer.
Ms. Brownley. And this is for any of the VSOs. Do you feel
an increased demand for a program like this amongst your
veterans?
Ms. Keleher. I personally have not heard specifically from
VFW members, but as--
Ms. Brownley. Do you think they know about the program?
Ms. Keleher. Personally, probably not, but I do hope they
do.
As we see the population of veterans continuously age, I
think we can all agree that we are going to see them not only
knowing the program more and more, but requiring it as well.
And I would assume that the quality outcomes are much better
than putting them in an institutionalized setting.
Ms. Brownley. Anybody else have a comment?
No?
With that, I will yield back.
Mr. Dunn. Thank you very much, Representative Brownley.
We now recognize Congressman Higgins for 5 minutes.
Mr. Higgins. Thank you, Mr. Chairman.
Ms. Bonjorni, thank you for your service to your country,
madam.
Do you see my bill, 5693, as a net win for America and
America's veterans?
Ms. Bonjorni. Yes. Thank you for the question, sir.
Mr. Higgins. That is the short answer. We can stop there.
Mr. Chairman, I yield back. I yield the balance of my time.
America wins. Veterans win, baby. That is why we are here,
right?
Mr. Dunn. Well, I thank you, Congressman Higgins. Let me
say that, as a veteran, when you retire and you need care, I
will give you care in my own home. How is that?
We now recognize Representative Kuster for 5 minutes. Thank
you.
Ms. Kuster. Thank you very much, Mr. Chairman.
And thank you to our panel and to all of our colleagues
introducing these bills. This is a great array of bills. And I
particularly appreciate the help from the VSOs and from the VA
as we sort them out.
I want to start by focusing my attention on Dr. Wenstrup's
bill, because we had a roundtable this morning with Dr. Roe. We
were talking about the issue of general medical education and
increasing the number of physicians being trained at the VA
going forward. And we were talking about what I would consider
to be unintended consequences of Dr. Wenstrup's concept about
measuring these RVUs as they are measured in the public domain,
in the public--I am sorry, in private medicine--and trying to
compare that to the VA.
And in particular, I think the VFW testimony talked about
there is value in tracking, but you have to be careful because
of the nonclinical burdens on VA health care providers.
In particular, could you comment--and to the VFW, but if
anyone else wants to comment--on the obligation of supervising
medical training? And so, for example, during residency, Dr.
Roe talked at length about the amount of time that that takes
and that you are not as efficient when you are doing that.
Could you comment on that? And also the specifics about
other elements that are different. For example, the physical
facilities, you don't have the same ratio of rooms for medical
appointments that you do in the private sector. You don't have
the same ratio of support staff that you do in the private
sector. How do these factors change the equation from trying to
compare apples to apples with RVUs?
Ms. Keleher. Thank you for the question. I will try to go
in order of the way that you did ask.
In regard to training, VA does provide ample training to
America's providers, whether they end up at VA or not. And that
is clearly very time consuming.
I use VA for all of my health care. And I have had many
times where my provider asks before the appointment if it is
okay if they have new residents come in, because they are going
through and explaining things more by process. There are
chances that the resident is not going to be as understanding
of things.
So that is a clearly very timely constraint on VA. And if
they are taking in more residents and doing more training than
in the private sector, that would be one great example of how
the RVUs could have a negative comparison.
VA also does a lot of research. They don't, as you said,
have all of the staff that in the private sector they may. And
the Subcommittee and the Committee at large have been wonderful
at trying to address those needs within VA. We are just a
little off still on the timing.
We do believe that the RVUs could provide great outcomes.
We do think that you are going to see the productivity
continuously increasing for VA.
But we are concerned about the way that will be used. Is
that going to be used for appropriation purposes? Are we going
to have a journalist pick it up and want to do another big
article about VA being less proficient, maybe, than the private
sector, when the private sector isn't publicly making that data
available simply because they don't have to, so why would they?
So it is something that we definitely are interested in
continuing to talk about with the Committee.
Ms. Kuster. Thank you very much.
And I do want to say on the record, I am all for efficiency
and would like to have further conversations about that.
I do want to make sure to get on the record that I support
Mr. Denham's bill with regard to medical waste. I am a
cosponsor of that bill. And just experience that I have on the
private sector with disposal of medical waste, I would like to
work with you all going forward to pass that bill.
And then, my time is very limited, but I did have a quick
question on--if I can get it in. I may have to take it for the
record. But this was on the whole issue about--I am sorry,
excuse me--the performance. But my time is up, so I will come
back another round. Thank you.
Mr. Dunn. Thank you, Representative Kuster.
I will now recognize Congresswoman Gonzalez-Colon for 5
minutes.
Miss Gonzalez-Colon. Thank you, Mr. Chairman.
I will go directly with Ms. Bonjorni.
First of all, I want to say that I do support Mr. Higgins'
bill. I don't know if you could so you can have both.
Anyway, you say that you have underway some of the proposal
of the bills under the Veterans Administration. I want to know
how many of those veterans or servicemembers were not working
anymore at the Armed Forces have already been hired at the
Veterans Administration. Do we have a rate?
Ms. Bonjorni. How many veterans are we hiring?
Miss Gonzalez-Colon. No, no. You say that you already have
the database, you are sharing the information from the
Department of Defense with the VA, correct?
Ms. Bonjorni. Yes.
Miss Gonzalez-Colon. You are having that effort already
undergoing.
Ms. Bonjorni. We have just received access to the data, and
so our targeted marketing toward specific occupations will be
starting by the end of this month.
Miss Gonzalez-Colon. Okay. So how long will it take for you
to make the whole program work? Because you said in your
written statement that it will take at least 180 days to make
that happen?
Ms. Bonjorni. Yes. So thank you for the question.
I think that in looking at what was actually the initial
draft of what is in the current law for the VA Choice and
Quality Employment Act, we are right now using our existing
personnel database to fulfill that requirement.
The data that we are receiving from DoD is specific to the
transitioning servicemembers. Right now that is not linked, the
two systems aren't linked. And so we would need some time, if
that is the long-term intent, to link those two sources of
information. But right now we are able to go ahead and use the
data about the transitioning servicemembers to market.
Miss Gonzalez-Colon. So it could be less time?
Ms. Bonjorni. Yeah.
Miss Gonzalez-Colon. Okay. So I like that answer.
And then my second question will be, you are saying that
there is intent of the administration to use, not just the
Department of Defense data, but using the whole government to
make that happen, correct?
Ms. Bonjorni. Could you elaborate on your question?
Miss Gonzalez-Colon. You said that the administration wants
to extend the database portion of the act of government-wide
intention to have access to the rest of the government instead
of using just the Department of Defense.
Ms. Bonjorni. I am not certain what other--what you are
allowing to be authorized.
Miss Gonzalez-Colon. In your written statement that is the
implication, that is what I read in that statement, that the
intention was not just the Department of Defense using the
database, but extending that to the rest of the government.
Ms. Bonjorni. As a long-term plan.
Miss Gonzalez-Colon. Exactly.
Ms. Bonjorni. But the VA is not actively pursuing that
right now, yes.
Miss Gonzalez-Colon. But it is on your written statement.
So maybe a long-term option is there, right?
Ms. Bonjorni. Yes.
Miss Gonzalez-Colon. So I do understand that this bill that
we just filed could be the best pilot program to have in the
public law to be enforced, and you already are having those
kind of ideas undergoing, but including--I mean, I think having
veterans serving veterans is the first thing. Saving taxpayers
money is the second biggest implementation of this bill.
Third, I think having the opportunity to cut the staffing
shortages that we have in the VA, the hiring process that is
always so difficult. We are facing that problem in Puerto Rico,
as a matter of fact.
And, of course, having the certifications for the ICTs that
you already have in place with remarkable reviews in so many
areas. Why not having that as not just a choice of public
policy in between the agency, but as a mandate of Congress?
And that is the reason of this bill, and I do support it.
And as you just said in your written statement, I do believe
that you are in support of it.
Ms. Bonjorni. Yes, we are in support.
Miss Gonzalez-Colon. Thank you. I yield back. I will do the
same thing that Mr. Higgins did.
Mr. Dunn. Thank you, Representative Gonzalez-Colon.
And we now recognize for 5 minutes Congressman Correa from
California.
Mr. Correa. Mr. Chairman, we will try to make it in 2. How
is that?
I just wanted to very quickly say I also support Mr.
Higgins' legislation. And wanted to also say that I joined
Representative Hartzler in introducing H.R. 5521 to address the
issue you are talking about, which is the physician shortage
and the ever-increasing physician shortage.
And I know that, Ms. Keleher, I know the VFW has some
issues, maybe some concerns. I hope we can work through those
issues and make sure they are all on board, because getting
good docs into the VA is an important goal. And I hope all of
us can work towards that.
With that, Mr. Chairman, I yield the remainder of my time.
Mr. Dunn. You have been very kind with the Committee's
time, Congressman Correa. Thank you very much for that.
Votes have been called, so the panel is going to be winding
down.
I do want to make the editorial comment that the use of
relative value units is not intended to be punitive. It is
intended to be a measure of productivity and efficiency. And I
think we have to get there somehow. Somehow we have to measure
our efficiency given the amount of the people's treasure that
has been entrusted to us in this Committee.
With that, I want to thank the panel for the time that you
have put in and for coming up here and being willing to see us
and talk to us and answer our questions.
The Subcommittee is adjourned.
[Whereupon, at 4:14 p.m., the Subcommittee was adjourned.]
A P P E N D I X
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Prepared Statement of Congresswoman Vicky Hartzler
Chairman Roe, Ranking Member Walz, and distinguished Members of the
Committee, thank you for allowing me this time to testify about HR
5521, The VA Hiring Enhancement Act.
Our veterans deserve the best. Unfortunately, top-notch care is
often hampered by a shortage of doctors at the VA. I believe that this
bill, which I introduced along with Congres7smen Correa and Congressman
Bost will help the VA to fill some of these vacancies.
Our bill has three main provisions. First, it would allow
physicians to be released from non-compete agreements only for the
purpose of serving in the VA for at least one year. Non-compete
agreements are supposed to prevent a physician from building up a
patient base, and then taking those patients with them as they set up
their own practice. A physician moving to the VA simply does not fit
that description. This provision would ensure that a non-compete
agreement is never used to keep a physician from serving veterans at a
VA facility, and only applies to such a circumstance.
Second, our bill updates the minimum training requirements for VA
physicians. Completion of a medical residency is widely accepted as
standard comprehensive training for clinical physicians in the United
States. However, current law only requires that a physician be licensed
in order to treat veterans. In the case of some medical specialties,
the difference between licensing and completing residency can represent
six years of training.
Some have suggested that this provision would exacerbate the
shortage of physicians at the VA by shrinking the pool from which the
VA can hire. However, the VA currently hires almost exclusively those
physicians which have completed residency training, so this provision
would not result in such an impact.
Others have rightly submitted that veterans are largely satisfied
with the quality of care they receive at the VA. They therefore submit
that we do not need to legislate a higher standard. I contend that as
long as Congress sees fit to impose any standard on the VA regarding
those caring for veterans, we have a duty to ensure that the standard
is appropriate. Completion of residency training is the accepted
standard in this nation, and we should never expect veterans to accept
anything less. This is a common-sense update to something federal law
already addresses, and ensures that only fully trained physicians care
for those who have served our nation.
Finally, our bill would place veterans' hospitals on a level
playing field with the private sector when it comes to recruiting
timelines. Often, private sector health care providers begin recruiting
medical residents as they begin their final year of residency,
sometimes even earlier.
Most residents have school debt they will need to start paying off-
an average of $190,000. During residency they treat patients and work
upwards of 80 hours a week, sometimes with single shifts up to 28
hours. These residents-rightfully motivated to secure a post-residency
job with better pay and better hours-often accept a solid job offer
from the private sector before VA recruiters are able to get their
recruiting process started.
Our bill authorizes VA recruiters to make job offers to physicians
up to 2 years prior to fulfilling all of the VA's requirements,
contingent on meeting all requirements before they begin treating
veterans. It offers job security to medical residents who want to work
at the VA when they complete their training, and allows VA facilities
and recruiters to shore up appointments further in advance, helping
them to plan and forecast medical workforce needs.
VA recruiters are already pitching a great opportunity for
physicians, and we owe them policies that make them as competitive as
possible with private sector recruiters. I believe that advancement of
this legislation will help begin to fill the VA's many vacant health
care positions.
We've worked closely with this Committee's staff, VA recruiters,
and VSOs on this bill, and I'm pleased to report that it has garnered
wide support, including formal endorsement from the American Legion and
Paralyzed Veterans of America. It's my hope we can work together to
move this bill to the House floor soon. Thank you again for allowing me
this time, I yield back.
Prepared Statement of Congressman Brad Wenstrup
Chairman, Members of the Health Subcommittee, thank you for
welcoming me back today.
As a Member of the House Veterans' Affairs Committee for many
years, one of my reoccurring frustrations was an inability to use
metric-driven standards to comprehensively examine and improve how the
VA was using its resources to deliver health care.
An axiom I heard often when I started on the Committee was that
``when you've seen one VA, you've seen one VA.''
My frustration grew every time I sat where you sit now, and asked
VHA's past leadership if they were able to provide metrics on health
care delivered per resources expended.
I was often told the numbers existed, but metrics never seemed to
materialize.
Reports
In foreshadowing the VA wait list crisis that became evident in
2014, VA's Office of the Inspector General issued a report in 2012,
entitled Audit of Physician Staffing Levels for Specialty Care
Services, finding that:
``VHA did not have an effective staffing methodology to ensure
appropriate staffing levels for specialty care services. Specifically,
VHA did not establish productivity standards for all specialties and VA
medical facility management did not develop staffing plans. This
occurred because there is a lack of agreement within VHA on how to
develop a methodology to measure productivity, and current VHA policy
does not provide sufficient guidance on developing medical facility
staffing plans. As a result, VHA's lack of productivity standards and
staffing plans limit the ability of medical facility officials to make
informed business decisions on the appropriate number of specialty
physicians to meet patient care needs, such as access and quality of
care.'' \1\
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\1\ https://www.va.gov/oig/pubs/VAOIG-11-01827-36.pdf
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The OIG went on to recommend that VHA:
``establish productivity standards for at least five specialty care
services by the end of FY 2013 and approve a plan that ensures all
specialty care services have productivity standards within 3 years. We
also recommended that the Under Secretary provide medical facility
management with specific guidance on development and annual review of
staffing plans.''
Five year later, the VA now tracks productivity metrics across more
than 30 specialties, but significant gaps persist in the effectiveness
and completeness of the current reporting. This inhibits their ability
to optimize resources to better deliver care to our veterans.
Last year, the GAO released a report entitled Improvements Needed
in Data and Monitoring of Clinical Productivity and Efficiency \2\.
This report found that current VA productivity metrics, including
relative value units, are not complete and may not be accurate.
Clinical specialties are siloed, certain inpatient work is not
measured, and contract providers go unmeasured. Data is not always
usefully accessible, and remediation plans do not rise above the VISN
level.
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\2\ https://www.gao.gov/assets/690/684869.pdf
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This GAO report contained four recommendations:
``1. expand existing productivity metrics to track the productivity
of all providers of care to veterans by, for example, including
contract physicians who are not VA employees as well as advance
practice providers acting as sole providers;
2. help ensure the accuracy of underlying staffing and workload
data by, for example, developing training to all providers on coding
clinical procedures;
3. develop a policy requiring VAMCs to monitor and improve clinical
efficiency through a standard process, such as establishing performance
standards based on VA's efficiency models and developing a remediation
plan for addressing clinical inefficiency; and
4. establish an ongoing process to systematically review VAMCs'
remediation plans and ensure that VAMCs and VISNs are successfully
implementing remediation plans for addressing low clinical productivity
and inefficiency.''
H.R. 6066
H.R. 6066 is legislation to tackle these recommendations by
tracking relative value units across all providers and providing a more
comprehensive and systematic review and reaction to the tracked data.
By more accurately tracking the work all our VA physicians and
health care providers conduct, we can better use existing resources to
deliver more care to our veterans. The GAO reported just a few examples
of how this data can help inform administrators, from reconfiguring
appointment scheduling to reprioritizing procedures to ensure the most
care possible can be delivered.
In my own career as a health care provider, I know that
productivity metrics, such as RVUs, can alert the caregiver that they
may be less efficient than they could be. This metric may bring to
light the need for greater medical assistance or more treatment rooms
being available.
Last year, working with the Committee, we drafted the language
found in this bill in response to the May 2017 GAO report and
recommendations, and from years of observation from the dais where you
now sit.
At that time, we worked to incorporate feedback from stakeholders,
including flexibility towards value-based care and accounting for non-
clinical duties. This language was included in H.R. 4242 when it passed
out of this very Committee last November, though did not make the final
VA MISSION Act.
That is why I am introducing this language as standalone bill. Our
veterans and our doctors deserve to know that all the VA's resources
are being optimized to deliver care.
The VA, like all government agencies, is operating in a resource
constrained environment. It is our obligation to make sure that the
resources we do have are directed at the veterans that need care. If we
can't measure this, we cannot improve.
In closing, I look forward to hearing input and perspective from
Members of the Committee, the VA, and VSOs on this legislation. None of
us can claim to have a monopoly on good ideas, and I stand ready to
work with all interested parties to make sure that every dollar we
spend within the Veterans Health Administration is being used to
effectively deliver care to our veterans.
Thank you.
Prepared Statement of Congressman Clay Higgins
Mr. Chairman,
My bill, HR 5693, the Long Term Care Veterans Choice Act,
authorizes the Department of Veterans Affairs (VA) for three years to
cover the cost of long-term care at medical foster homes for up to 900
veterans otherwise eligible for nursing home care through the VA.
Medical Foster Homes (MFH) are private homes in which a caregiver
provides services to a small group of individuals who are unable to
live without day to day assistance, and are an alternative to nursing
homes for those who require nursing home care but prefer a non-
institutional setting with fewer residents. For many young veterans in
need of round-the-clock-care, MFHs can provide a more age-appropriate,
independent setting than traditional nursing homes.
The US Department of Veterans Affairs (VA) has run its medical
foster home initiative since 2000, and today the Veterans Health
Administration oversees more than 700 licensed caregivers caring for
nearly 1,000 veterans in 42 states. To be eligible to provide care to
veterans, VA medical foster home providers must already pass a
background check, complete 80 hours of initial training and 20 hours
annually afterwards, and cannot work outside the home.
Unfortunately, while the VA will cover the cost of Home Based
Primary Care for eligible veterans living in MFHs, the VA does not
cover the cost of MFH living arrangements for veterans otherwise
eligible for nursing home care through the VA. Instead, these veterans
must pay for MFH services out of pocket or through private insurance.
Costs associated with MFH services range between $1500 - $3000 a month,
which is significantly lower than the nearly $7,000 VA would otherwise
pay per patient at a state VA nursing home.
In my home state of Louisiana, the VA operates state of the art
Veterans Homes that provide residents a high quality of care in an
understanding, supportive environment. Last summer I toured the
Southwest Louisiana Veterans Home in Jennings and I can personally
attest to the high quality of care and sense of well-being among
veterans. But much like in the civilian world, there is no one-size-
fits-all standard of care for veterans. Veterans should be afforded
flexibility to use the benefits they righteously earned in a manner
that best suits their individual needs.
HR 5693 gives much needed choice and personal agency back to these
brave men and women who have selflessly sacrificed for our nation.
Thank you.
Prepared Statement of Congressman Mike Bost
H.R. 5864 - VA Hospitals Establishing Leadership Performance Act
Script
Thank you Mr. Chairman and Ranking Member Brownley for providing me
the opportunity to testify before the Subcommittee on Health on my
legislation, H.R. 5864, the VA Hospitals Establishing Leadership
Performance Act or VA HELP Act.
The mission of the Department of Veterans Affairs is to care for
those ``who shall have borne the battle.'' When our heroes transition
from the military, they deserve to have access to quality healthcare
and services.
Unfortunately, VA continues to fall short on that promise, due in
part to failures in human resources management and operations. VA's
internal assessments, and those by the Government Accountability Office
and VA Inspector General, have identified serious human capital
challenges and weaknesses within VHA's Human Resources operations. Most
recently, we all heard about inadequate staffing and human resource
management deficiencies that contributed to failures at the Washington
DC VAMC.
This issue hit close to home for me after the VA National Center
for Patient Safety surveyed the Marion VA Medical Center.
The Marion VA's Patient Safety Culture Survey showed a considerable
decline in key factors such as communication between management and
staff and the frequency of reporting problems to management. During the
site visit, multiple employees raised concerns about poor management
and poor communication, distrust between leadership and management, and
the lack of accountability.
These factors help measure the culture at VA facilities, and it was
clear that employees were unsatisfied with their work environment.
Following this report, General Bergman and I sent a letter to then
Secretary Shulkin requesting that the VA further investigate this
matter. This effort was followed-up by an Oversight and Investigations
Subcommittee staff visit to the Marion VAMC in order to get a firsthand
look at the issues at the facility.
A report of the Subcommittee's findings confirmed a lack of
accountability, improper communication and a lack of standards to
measure the success of the HR department. We also learned that you do
not need a college degree to be a Chief of Human Resources in the VA. I
do not know of any health system that has a Chief of HR without a
college degree overseeing thousands of employees and responsible for
negotiating job offers and proposing disciplinary actions. I also do
not know of any health system that would hire or promote an individual
to manage and oversee a human resources department without requiring a
college degree.
During my time on this Committee I have seen that it is common in
VA to move problem employees into high-level jobs with greater
responsibility, without assessing their prior leadership experience and
performance.
Unfortunately, despite the Subcommittee's findings and several
efforts to encourage VA Headquarters leadership to address these
problems, limited actions have been taken. My office continues to
receive complaints about the mistrust of medical center leadership,
confusion and inconsistencies in disciplinary processes, and failures
to track employee performance and outcomes.
Human resource management is a critical part of delivering quality
healthcare. HR is responsible for recruiting and retaining highly
qualified professionals, and the current status quo within VHA's HR
offices cannot continue.
H.R. 5864, the VA HELP Act will ensure that the VA addresses
deficiencies within its Human Resources departments by giving it the
ability to compare the performance of departments across VHA and
measure their success.
This straightforward legislation instructs the Secretary of
Veterans Affairs (VA) to establish qualifications for Human Resources
positions within the Veterans Health Administration (VHA). It also
requires the VA to establish standardized performance metrics for Human
Resources positions. These commonsense reforms will ensure that the
Human Resources departments at VAMCs are operating on a uniform
standard, and that it is clear who qualifies to hold such an important
position.
In closing, I would like to thank Representative Sinema for helping
to introduce the legislation and would like to thank you, Mr. Chairman
and Ranking Member Brownley, for allowing me to testify before the
Subcommittee. I hope that we can work together on H.R. 5864 to ensure
that our nation's veterans are being provided the best possible care
from VA employees.
Prepared Statement of The Honorable Jenniffer Gonzalez-Colon
Chairman Neal Dunn, Ranking Member Julia Brownley, thank you for
this afternoon's legislative hearing and thank you for including H.R.
5938, the Veterans Serving Veterans Act as part of the agenda. I would
also like to thank the panel for their testimony.
Mr. Chairman, as previously stated on several occasions before this
Committee, the Department of Veterans' Affairs (VA) suffers chronic
staffing challenges that at times complicate the delivery of proper and
timely care. These challenges are often exacerbated by a complex and
time-consuming hiring process that extends the time in between the need
for a position, and filling it with appropriate staff members. VA
facilities within my district are no exception. As a matter of fact,
this issue never fails to come up during meetings with veterans in
Puerto Rico. Therefore, as an effort to identify a remedial option, the
Veterans Serving Veterans Act seeks to amend section 208 of the Choice
and Quality Employment Act of 2017 to include Military Occupational
Specialties (MOS) that correspond to vacant positions at the VA in the
recruiting database, as well as service member's contact information,
date of discharge, and the MOS they have acquired.
Employment after separating from the military is beneficial for
veterans from a psychological and financial perspective. A process for
identifying separating service members with military occupational
specialties that match VA position needs and matching them with open
positions will be valuable for both the service member and the VA.
Therefore, H.R. 5938 will require VA to:
Coordinate with DOD to identify soon to be separated
service members with military occupational specialties needed by VA and
to obtain their military specialties, date of separation, and contact
information.
Maintain a database searchable by VA personnel for
purposes of hiring soon to be separated service members; and,
Implement direct hiring and appointment procedures for
vacant positions listed in the database for service members who apply
for these positions.
Lastly, Section 3 of H.R. 5938 is designed to assist our veterans
by requiring VA to implement a program to train and certify former
Department of Defense healthcare technicians as Intermediate Care
Technicians (ICTs), and to address the large demand for healthcare
providers at the Veterans Health Administration (VHA). Currently, these
very skilled technicians, trained at significant taxpayer expense, have
difficulty gaining employment in their field of specialization after
separation from the Armed Forces due to lack of a certification. At the
same time, VHA has a significant shortage of providers.
VHA instituted the Intermediate Care Technician Pilot Program in
2013 to train and utilize ICTs at VA facilities in a variety of roles.
In March 2015, the program was expanded and has since then received
remarkable satisfaction rates and helped fill a void of medical
providers within VA medical centers. As of April 2017, 25 VA Medical
Centers are utilizing ICTs, are in the process of hiring ICTs, or have
indicated the intent to hire ICTs. 34 ICTs have been hired since the
end of the pilot.
Despite the high success rate of the program, it is currently
operating in a case by case basis, contingent on availability of funds
at individual medical centers, and with a limited number of training
centers. Implementing a program to train and certify eligible veterans
to work as ICTs will provide for continued program support and
expansion, ensure rigor in curriculum development, competency
assessment, and program monitoring, and allow the pool of eligible ICTs
to continue growing to meet veterans' healthcare needs.
Mr. Chairman, it is important to keep in mind that service members
are a remarkable asset upon transitioning from military service. The
Department of Defense invests millions of dollars in their training,
and they develop skills that have proven valuable to the Department of
Veterans' Affairs. This bill seeks to further close the gap between
transitioning members and the VA by helping them occupy positions
currently in demand at the Department and provides an opportunity for
greater access to medical care. Moreover, it allows for veterans to be
cared by fellow veterans in ways that are most needed by the VA at this
moment.
Again, thank you for including it in today's agenda. I look forward
to receiving feedback from our panel and fellow colleagues on ways to
move forward with this bill.
Thank you.
Prepared Statement of Honorable Jeff Denham
HR 5974, the VA COST SAVINGS Enhancements Act
Mr. Chairman: Thank you for the opportunity to speak in support of
HR 5974, the VA COST SAVINGS Enhancements Act.
I introduced this bipartisan bill to improve care for our veterans
and ensure we are using the latest cost-saving technology.
Specifically, it directs the VA to install on-site medical waste
treatment systems in facilities where this will result in a cost-
savings within 5 years.
System-wide, this will save the VA millions of dollars each year
and directly improve safety and healthcare for our veterans.
Medical waste, also known as ``red bag'' or ``biohazardous'' waste,
is infectious waste produced at VA facilities and hospitals.
Since this waste is contaminated by blood or bodily fluids, it
poses a risk of transmitting an infection and has to be handled in a
special way.
If a VA facility has an on-site sterilization machine, this waste
can be disinfected immediately. Otherwise, it must be taken to a
special facility off-site.
On-site sterilization machines, or autoclaves, are steam
sterilizers that use temperature and pressure to compact waste and
destroy all microbial life.
This process renders a completely safe byproduct that can be
disposed of as normal waste.
This technology is vetted by the EPA, and is considered a best
practice by the Centers for Disease Control and Prevention (CDC) and
World Health Organization (WHO).
So, this policy brings the VA in line with the medical community's
recommended practices.
When VA facilities do not treat waste on-site, they have to load it
in trucks and drive it to regional waste disposal centers. This is both
inefficient and expensive.
It can't be compacted otherwise infections will spread, so the
trucks fill up fast.
Additionally, contracting with third parties to ship this waste is
expensive.
In a report to Congress, the VA found that on-site treatment costs
half as much as hauling waste off-site. Often much less.
Current technologies can treat waste for 7 to 9 cents per pound,
compared to 30 to 60 cents off-site.
We are wasting millions of dollars each year shipping infectious
waste around the country. My bill stops that.
In addition to the enormous cost savings, this technology is safer,
more environmentally friendly, and increases crisis readiness.
Safety is paramount when caring for out vets, and treating waste
on-site prevents the spread of infections. That is why the CDC
recommends this technology.
It also reduces carbon emissions.
HR 5974 eliminates the need for hundreds of trucks to be on the
road, and stops VA hospitals from shipping infectious waste back
through the communities they serve.
Furthermore, it enhances operational stability and improves
disaster response.
In the event of an earthquake or flood, transportation
infrastructure can be compromised and prevent trucks from reaching a
facility.
This ends reliance on outside contractors and ensures medical waste
can be immediately dealt with in a disaster scenario.
The VA recognizes the benefits of this technology and approximately
20% of VA facilities have already installed on-site sterilization.
The 2016 Military Construction and Veterans Affairs Appropriations
bill acknowledges `there are cost savings as well as beneficial
environmental impacts and [energy] savings associated with on-site
medical waste treatment.''
Accordingly, the VA developed a Blanket Purchase Agreement to
streamline purchasing of these machines. Unfortunately - implementation
has been slow.
It is time to realize the full benefits of this technology and
bring the VA into the 21st century.
Our veterans deserve the highest-quality care we can provide.
This technology improves crisis-readiness, and is safer, more
efficient, more cost-effective, and more environmentally friendly than
traditional medical waste disposal.
Installing these machines will immediately begin saving the VA
millions of dollars per year, and directly improve care for our
veterans.
I urge my colleagues to support this policy.
Prepared Statement of Congressman Matt Cartwright
Chairman Dunn, Ranking Member Brownlee, and Members of the
Committee, thank you for including H.R. 3696, the Wounded Warrior
Workforce Enhancement Act, as part of the hearing today and for the
opportunity to speak to the Committee about this very important piece
of legislation.
Additionally, I would like to thank the American Orthotics and
Prosthetics Association as well as Senator Durbin as they have been
instrumental in focusing attention on this critical issue facing our
nation's veterans.
The field of orthotics and prosthetics is at a critical tipping
point in terms of the future viability of its workforce and the ability
of those professionals to provide the best-tailored care to our
nation's service members and veterans.
The American Orthotics and Prosthetics Association has stated that
there has an approximately 300% increase in the number of veterans with
amputations served by the VA since the year 2000.
Unfortunately, currently only 7100 practitioners specially trained
in O&P nationwide serve more than 80,000 vets with amputations. Of
those trained practitioners, one in five is either past retirement age
or eligible to retire in the next five years.
However, there are only 13 schools around the country with master's
degree programs in this field with the largest program supporting less
than 50 students.
With the growing demand of amputee treatment outpacing the number
of new practitioners trained to replace an aging workforce, it is clear
that we must act now to meet our moral obligation of providing our
heroes with the best health care available.
The Wounded Warrior Workforce Enhancement Act is a cost-effective
approach to assisting universities in creating or expanding accredited
master's degree programs in orthotics and prosthetics.
Specifically, the bill addresses these issues by authorizing a
competitive grant of program of $5 million per year for 3 years to help
colleges and universities develop master's degree programs focusing on
orthotics and prosthetics.
The bill also requires the VA to establish a Center of Excellence
in Prosthetic and Orthotic Education to provide evidence-based research
on the knowledge, skills, and training clinical professionals need to
care for veterans.
These prosthetic and orthotic treatments serve soldiers who
suffered limb loss injuries because they put their bodies on the line
for our country, and as a result, have their lives forever changed.
With Veterans Day just last week, it is a very good reminder just how
much we owe our wounded warriors.
Thank you again Chairman Dunn, Ranking Member Brownlee, and Members
of the Committee for your consideration of this bill today and for
bringing attention to the important issue of providing veterans with
the best possible prosthetic and orthotic treatment possible. I look
forward to working with you and your staff on advancing this important
piece of legislation.
Prepared Statement of The Honorable Marcy Kaptur (D-OH)
Concerning
H.R. 2787, the Veterans-Specific Education for Tomorrow's Medical
Doctors (VET MD) Act
Chairman Dunn, Ranking Member Brownley, and members of the
Subcommittee, thank you for the invitation to appear before you today.
I truly appreciate the opportunity to join you to discuss how we can
increase opportunities for future physicians interested in veterans'
health care. At the same time, we have the potential to address the
critical physician shortage facing the Veterans Health Administration.
Thank you for including in today's hearing, bipartisan legislation
I introduced to create a shadowing program for pre-medical
undergraduate students who need to gain clinical observation
experience. H.R. 2787, the Veterans-Specific Education for Tomorrow's
Medical Doctors (VET MD) Act, would expose America's future physicians
to the unique needs faced by our veteran population. This exposure
would better prepare future physicians to provide veteran-centered care
no matter where they choose to practice.
Several years ago, two pre-medical undergraduate students
highlighted to my team the struggles disadvantaged, minority, and other
young people who lack personal and familial connections in medical
communities face as they apply for medical school. Through their own
struggle to access clinical observation experience, they realized an
immense opportunity.
In the current medical school admissions system, 73 percent of
medical schools either highly recommend or require applicants to have
clinical observation experience. \1\ In fact, medical schools recommend
applicants have 40 hours of observation experience at minimum. However,
there is no formal system through which students can apply to shadow or
observe clinicians in hospital or clinical settings.
---------------------------------------------------------------------------
\1\ Association of American Medical Colleges. (2016). Clinical
Experiences Survey Summary. Retrieved from https://www.aamc.org/
download/474256/data/gsa-coa-clinical-shadowing-experience-executive-
summary.pdf
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More than 87 percent of medical schools report that applicants
without clinical observation experience may be at a disadvantage in the
admissions phase and that preference tends to be given to applicants
with observation experience. \2\ Further exacerbating the situation,
opportunities for clinical observation are very limited. Students from
or who attend schools outside major cities and whose families lack
connections to the medical community are at a significant disadvantage
in the search to find clinical observation opportunities.
---------------------------------------------------------------------------
\2\ Association of Medical Colleges, Ibid.
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In 2015, the percentage of Black or African American medical school
graduates was 6 percent and Hispanic or Latino medical school graduates
was 5 percent. \3\ Whites and Asians continue to represent the largest
proportion of medical school graduates with 58.8 percent and 19.8
percent respectively. \4\ Yet, as the American population becomes more
diverse, the same trends are anticipated of our veteran population too.
In the next thirty years, the number of veterans who are non-Hispanic
White is expected to drop from 77 percent to 64 percent. The number of
Hispanic veterans is expected to nearly double from 7 percent to 13
percent, while the number of Black veterans is expected to increase
from 12 percent to 16 percent. \5\ It is vital we work to find
solutions to build and increase the diversity of the physician
pipeline. We know that a more diverse medical profession means better
care for a diverse America, especially for our veterans.
---------------------------------------------------------------------------
\3\ Association of American Medical Colleges. (2016). Current
Trends in Medical Education. Retrieved from http://
aamcdiversityfactsandfigures2016.org/report-section/section-3/
\4\ Association of American Medical Colleges, Ibid.
\5\ Bialik, K. (2017, November 10). The changing face of America's
veteran population. Retrieved from http://www.pewresearch.org/fact-
tank/2017/11/10/the-changing-face-of-americas-veteran-population/
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After working closely with experts at the VA, their recommendations
were included in the discussion draft to ensure the pilot program is
more manageable for VA hospitals, clinicians, and participating
students and we prioritize student applicants from Minority-Serving
Institutions. These revisions do not change the underlying intent of
the original bill, to create a pilot program for undergraduate pre-
medical students to participate in clinical observation opportunities.
While the primary purpose of this bill is to provide a pathway for
pre-med students to gain valuable shadowing hours, an important
secondary goal is to address the physician shortage at the VA. Not only
does the VA have a high demand for physicians, a critical needs
occupation according to the VA Office of Inspector General (OIG),
recruitment and retaining of physicians are both especially
challenging. In an FY17 report from the VA OIG, total gains in critical
needs occupation were offset by total losses. \6\ As you all are
acutely aware, the VA is facing many staffing challenges.
---------------------------------------------------------------------------
\6\ Department of Veterans Affairs Office of the Inspector General.
(2017, September). OIG Determination of VHA Occupational Staffing
Shortages FY2017. Retrieved from https://www.va.gov/oig/pubs/VAOIG-17-
00936-385.pdf
---------------------------------------------------------------------------
In a 2017 Government Accountability Office (GAO) report about
physician staffing at the VHA, the GAO identified incomplete data
issues which prevented the VHA to accurately count the number of
physicians who provide care at VA Medical Centers. This report also
identifies that the VHA is unable to estimate their own staffing
shortages due to data collection issues. \7\ However, the United States
overall will face a physician shortage of between 40,000 and 104,000 by
2030, according to the Association of American Medical Colleges. \8\
Even though the VA's share of that immense shortage is unknown, Members
of Congress must be able to craft creative solutions to make a dent in
those enormous numbers.
---------------------------------------------------------------------------
\7\ U.S. Government Accountability Office. (2017, October 19).
Veterans Health Administration: Better Data and Evaluation Could Help
Improve Physician Staffing, Recruitment, and Retention Strategies.
Retrieved from https://www.gao.gov/products/GAO-18-124
\8\ Research Shows Shortage of More than 100,000 Doctors by 2030.
(2017, March 14). Retrieved from https://news.aamc.org/medical-
education/article/new-aamc-research-reaffirms-looming-physician-shor/
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Creating a pipeline of physicians with veteran specific exposure at
an early point in medical training is incumbent upon us as
policymakers. As health professionals serving within the VHA are well
aware, men and women who have served in the armed forces have specific
medical needs such as exposure-based conditions and mental health
issues.
A deeper understanding of veterans' specific health needs and
experiences is critical for these health professionals. This pilot
program has great potential to train the next generation of VHA
physicians. Our number one priority is to ensure that our veterans,
those who have sacrificed so much for their country, receive high
quality health care from highly trained physicians. We have a
responsibility as Members of Congress to guarantee that health
professionals who serve those who served us, are highly trained in
practicing medicine and in veteran centered care.
Thank you again for inviting me to testify regarding H.R. 2787, the
VET MD Act. This legislation will allow the VA to create a pilot
program for pre-med students to gain the observation experience they
need to become qualified medical school applicants. I look forward to
working with you to move this bill forward and am happy to answer any
questions you may have.
Prepared Statement of Roscoe Butler
Chairman Dunn, Ranking Member Brownley and distinguished members of
the Subcommittee on Health; on behalf of National Commander Denise H.
Rohan and The American Legion, the country's largest patriotic wartime
veterans service organization, comprising over 2 million members and
serving every man and woman who has worn the uniform for this country,
we thank you for the opportunity to testify on the following pending
and draft legislation.
H.R. 2787 - Veterans-Specific Education for Tomorrow's Medical Doctors
Act
To establish in the Department of Veterans Affairs a pilot program
instituting a clinical observation program for pre-med students
preparing to attend medical school.
The American Legion is deeply troubled by the Department of
Veterans Affairs (VA) leadership, physicians and medical specialist
staffing shortages within the Veterans Health Administration (VHA).
Since the inception of our System Worth Saving program in 2003, The
American Legion has identified, and reported staffing shortages at
every VA medical facility and reported these critical deficiencies to
Congress, the VA Central Office (VACO), and the President of the United
States.
In 2018, VA reported there were more than 33,000 full-time
vacancies. \1\ Many of these vacancies included hard-to-fill clinical
positions, as well as occupations identified under 38 U.S.C. 7412.
These findings were reinforced by a VA's Office of Inspector General
(VAOIG) report determining the largest critical need occupations are
medical officers, nurses, psychologists, physician assistants, and
medical technologists. \2\ The VA needs to identify and attract as many
qualified candidates as possible as soon as possible.
---------------------------------------------------------------------------
\1\ VA Vacancies - https://www.washingtonpost.com/world/national-
security/trump-says-veterans-wait-too-long-for-health-care-vas-33000-
vacancies-might-have-something-to-do-with-that/2018/04/10/d20bc890-
3ccf-11e8-974f-aacd97698cef--story.html?noredirect=on&utm--
term=.58facbebf668
\2\ VAOIG Report 17-00936-835
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This bill requires the Secretary of the Department of Veterans
Affairs to carry out a pilot program to provide undergraduate students
a clinical observation experience at VA medical centers.
Currently, VHA provides care at more than 1,233 healthcare
facilities, including 168 VA medical centers and 1,063 VHA outpatient
clinics. \3\ The American Legion believes access to basic healthcare
services, offered by qualified providers, should be broadly available
and staffed with the best personnel. Establishing a clinical
observation program for premedical students preparing to attend medical
school can serve as a recruiting tool to attract individuals who may
not have considered VHA. VA recognizes the value of such programs as
they already conduct the largest education and training programs for
health professionals in the United States. \4\ VA has affiliations with
more than 1,800 educational institutions; more than 70 percent of all
doctors in the U.S. have received training in the VA healthcare system.
\5\
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\3\ VHA: Where do I get the care I need?:https://www.va.gov/health/
findcare.asp'
\4\ VA News Release dated February 12, 2016: https://www.va.gov/
opa/pressrel/includes/viewPDF.cfm?id=2747
\5\ Id.
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Through American Legion Resolutions No. 115, Department of Veterans
Affairs Recruitment and Retention, \6\ and No. 377, Support for Veteran
Quality of Life, we support legislation addressing recruitment and
retention challenges, and any legislation or programs within VA that
enhance, promote, restore or preserve benefits for veterans and their
dependents, including, but not limited to, the following: timely access
to quality VA health care, timely decisions on claims and receipt of
earned benefits, and final resting places in national shrines with
lasting tributes that commemorate their service. \7\
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\6\ The American Legion Resolution No. 115 (2016): Department of
Veterans Affairs Recruitment and Retention
\7\ The American Legion Resolution No. 377 (2016): Support for
Veteran Quality of Life
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The American Legion supports H.R. 2787.
H.R. 3696 - Wounded Warrior Workforce Enhancement Act
To require the Secretary of Veterans Affairs to award grants to
establish, or expand upon, master's degree programs in orthotics and
prosthetics, and for other purposes.
The American Legion believes, due to the shortage of physicians in
certain specialized areas, such as orthotics and prosthetics, Congress
must ensure resources and funding are available to support their
continued education and training. We know there will be a continual
increasing need for clinicians at the master degree level to meet this
demand as the number of veterans needing orthotics and prosthetics
services increases. \8\
---------------------------------------------------------------------------
\8\ American Orthotic and Prosthetic Association Testimony
www.aopanet.org/wp-content/.../AOPA-VA-Health-Subcommittee-Testimony-
5.2.pdf
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According to May 2, 2017 testimony provided by the American
Orthotic and Prosthetic Association, in past wars 3 percent of
servicemembers injured required amputations in previous wars; of those
wounded in Iraq, 6 percent have required amputations. In the year 2000,
the VA served 25,000 veterans with amputations, according to the VHA
Amputation System of Care figures. By 2016, that number had more than
tripled to 89,921. Between 2008 and 2013, VA performed an average of
7,669 new amputations for veterans every year; in 2016, the number of
amputation surgeries rose to 11,879.
This bill would authorize the Secretary of the VA to award grants
to eligible institutions enabling schools to establish a master's
degree program in orthotics and prosthetics; or to expand upon an
existing master's degree program in orthotics and prosthetics,
including; by admitting more students, further training faculty,
expanding facilities, or increasing cooperation with VA and the
Department of Defense. This Wounded Warrior Workforce Enhancement Act
recognizes the ever-increasing need for specialists in orthotics and
prosthetics.
Through American Legion Resolution No. 311, The American Legion
Policy on VA Physicians and Medical Specialist Staffing Guidelines, we
support this bill. \9\ VA will benefit from the medical professionals
who complete the program and continue to serve veterans at medical
centers around the world.
---------------------------------------------------------------------------
\9\ The American Legion Resolution No. 311 (1998): The American
Legion Policy on VA Physicians and Medical Specialists Staffing
Guidelines
---------------------------------------------------------------------------
The American Legion Supports H.R. 3696.
H.R 5521 - VA Hiring Enhancement Act
To amend title 38, United States Code, to provide for the non-
applicability of non-Department of Veterans Affairs covenants not to
compete to the appointment of certain Veterans Health Administration
personnel, to permit the Veterans Health Administration to make
contingent appointments, and to require certain Veterans Health
Administration physicians to complete residency training.
The American Legion, as previously stated, has long expressed
concern about staffing shortages at VA/VHA medical facilities to
include physicians and medical specialist staffing.
The VA Hiring Enhancement Act will help address the shortcomings in
recruitment and retention of highly qualified physicians. The bill
allows VA to make binding job offers up to 2 years prior to completion
of medical residency, eliminating much of the bureaucratic red tape
that slows the hiring of newly recruited individuals. This legislation
allows physicians completing their education to immediately begin
treating veterans. By allowing VA to make binding offers, veterans will
receive treatment by qualified physicians that have completed their
residency. This bill aligns the hiring practices of VA to those of the
private sector ensuring top quality healthcare is provided to our
veterans.
Further, this bill also releases physicians from ``non-compete
agreements'' for the purpose of serving in the VHA. The American Legion
believes enforcing non-compete agreements to VHA hires is over-broad
and should be unenforceable under public policy. Traditional reasoning
behind non-compete agreements to bar competitive advantages or protect
sensitive information simply do not exist in this context.
Through American Legion Resolution No. 115, Department of Veterans
Affairs Recruitment and Retention, we support legislation addressing
the recruitment and retention challenges of the Department of Veterans
Affairs. \10\ We support legislation that addresses pay disparities
among physicians and medical specialists who are providing direct
health care to our nation's veterans.
---------------------------------------------------------------------------
\10\ The American Legion Resolution No. 115 (2016): Department of
Veterans Affairs Recruitment and Retention
---------------------------------------------------------------------------
The American Legion supports H.R. 5521.
H.R. 5693 - Long-Term Care Veterans Choice Act
To amend title 38, United States Code, to authorize the Secretary
of Veterans Affairs to enter into contracts and agreements for the
placement of veterans in non-Department medical foster homes for
certain veterans who are unable to live independently.
Veterans Health Administration directive provides specific policy
and guidance for establishing and operating a Medical Foster Home (MFH)
Program under the standards of the Department of Veterans Affairs
Community Residential Care (CRC) Program, of which it is a sub-
component. Medical Foster Homes serve as an alternative to nursing home
care for veterans unable to live without day-to-day assistance, while
also providing a non-institutional setting with fewer residents.
Currently, veterans enrolled in Home Based Primary Care through the
VA may elect to receive their care at MFHs. However, veterans eligible
for nursing home care through the VA are not eligible to receive their
care at MFHs, nor does the VA cover the cost of these living
arrangements. Instead, these veterans must pay for MFH services out of
pocket or through private insurance. Costs associated with MFH services
are significantly lower than what the VA would otherwise pay per
patient at a state VA nursing home.
This bill would require the Secretary of the VA, beginning on
October 1, 2019, to provide nursing home care under section 1710A, at
the request of a veteran. The Secretary may then place the veteran in a
medical foster home that meets Department standards, at the expense of
the United States, pursuant to a contract or agreement entered into
between the Secretary and the medical foster home for such purposes. A
veteran who is placed in a medical foster home under this authority
shall agree, as a condition of such placement, to accept home health
services furnished by the Secretary under title 38 U.S.C. 1717.
Medical Foster Homes are private homes in which a caregiver
provides services to a small group of individuals who are unable to
live without day to day assistance. MFHs are an alternative to nursing
homes for those who require nursing home care but prefer a non-
institutional setting with fewer residents. When one or more eligible
veterans reside in a MFH, the VA ensures that the MFH caregiver is
well-trained to provide VA planned care.
Allowing veterans to exercise greater flexibility over their
benefits ensures that their individual needs are best met. This
legislation offers a cost-saving alternative to nursing home care,
while providing veterans with more personal, quality health services.
This is reflective of our overall effort to provide veterans with
greater choice and freedom over their benefits while preserving the VA
system.
Through American Legion Resolution No. 114, Department of Veterans
Affairs Provider Agreements with Non-VA Providers, we support
legislation allowing the Department of Veterans Affairs to enter into
provider agreements with eligible non-VA providers to obtain needed
healthcare services for the care and treatment of eligible veterans.
\11\ The VA must be authorized to obtain healthcare services from non-
VA providers, particularly when it is most effective for the veteran
and the taxpayer.
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\11\ The American Legion Resolution No. 114 (2016): Department of
Veterans Affairs Provider Agreements with Non-VA Providers
---------------------------------------------------------------------------
The American Legion supports H.R. 5693.
H.R. 5864 - VA Hospitals Establishing Leadership Performance Act
To direct the Secretary of Veterans Affairs to establish
qualifications for the human resources positions within the Veterans
Health Administration of the Department of Veterans Affairs, and for
other purposes.
The provisions in this bill fall outside the scope of established
resolutions of The American Legion. The American Legion does not have a
resolution that addresses qualification standards and performance
metrics for VHA human resource positions. As a large, grassroots
organization, The American Legion takes positions on legislation based
on resolutions passed by our membership. With no resolutions addressing
the provisions of the legislation, The American Legion is researching
the material and working with our membership to determine the course of
action that best serves veterans.
The American Legion has no position on H.R. 5864.
H.R. 5938 - Veterans Serving Veterans Act of 2018
To amend the VA Choice and Quality Employment Act to direct the
Secretary of Veterans Affairs to establish a vacancy and recruitment
database to facilitate the recruitment of certain members of the Armed
Forces to satisfy the occupational needs of the Department of Veterans
Affairs, to establish and implement a training and certification
program for intermediate care technicians in that Department, and for
other purposes.
On August 12, 2017, Congress passed and the President signed into
law, Public Law 115-46, the VA Choice and Quality Employment Act of
2017. This law established a recruiting database covering every vacancy
in VA, with the ability to select applicants for positions other than
the one for which they originally applied. The Veterans Serving
Veterans Act of 2018 will expand the existing database to include
members of the Armed Forces in the talent pool to meet the Department's
occupational needs.
The American Legion strives to ensure our veterans and their
families receive the support and recognition they deserve. Every member
of our organization is a wartime veteran, so we understand the value of
our fellow citizens' support during and after our military service.
Saying thank you is only the beginning of how we should honor America's
newest generation of warriors and veterans. This bill recognizes
servicemembers require continued support and recognition of their
unique skills and needs.
The database, to be known as the Recruitment Database of the
Department of Defense and the Department of Veterans Affairs, would
provide the military occupational specialty or skills that corresponds
to each vacant position, in consultation with the Secretary of the
Department of Defense, as well as with each qualified member of the
Armed Forces who could be recruited to fill the position before their
separation from active service. This bill would require the Secretary
of the VA to implement direct procedures for hiring and appointment for
the vacant positions that appear in the database for qualified members
of the Armed Forces that apply to these positions.
Further, The Veterans Serving Veterans Act of 2018 also requires
the Secretary of VA to implement a program to train and certify covered
veterans to work as Intermediate Care Technicians (ICTs) in the
Department. A ``covered veteran'' will be defined as a veteran who the
Secretary determines served as a basic health care technician while
serving in the Armed Forces. This recognizes our warfighters within all
branches of the Armed Forces with training and experience in medical
care, but do not have a civil certification to continue providing these
services once they are separated from the military.
The American Legion has long recognized the need for certification
of skills earned in the military since it championed the Veterans
Skills to Jobs Act, signed into law in 2012. Legionnaires at the state
and post levels have, and will continue to demand their legislatures
and general assemblies pass new licensing and credentialing laws in
their states affirming skills of separating servicemembers. The
economics are easy to understand. The military and the taxpaying public
have already paid for these veterans to be trained. Forcing veterans to
spend taxpayer-funded education benefits on certification classes is
the equivalent of paying them to be trained twice, and it places an
unnecessary burden on veterans trying to make the transition to
civilian careers.
Through American Legion Resolution No. 115, Department of Veterans
Affairs Recruitment and Retention, we support legislation addressing
the recruitment and retention challenges of the Department of Veterans
Affairs. \12\ We support legislation calling on VA to work more
comprehensively with community partners when struggling to fill
critical shortages within VA's ranks. Adding qualifying members of the
Armed Forces who may be recruited to fill positions in the VA before
the member of the Armed Forces has been discharged and released from
active duty fulfils these criteria as well as supports our nation's
warfighters transitioning out of the military.
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\12\ The American Legion Resolution No. 115 (2016): Department of
Veterans Affairs Recruitment and Retention
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The American Legion supports H.R. 5938.
H.R. 5974 - VA COST SAVINGS Enhancement Act
To direct the Secretary of Veterans Affairs to use on-site
regulated medical waste treatment systems at certain Department of
Veterans Affairs facilities, and for other purposes.
The provisions in this bill fall outside the scope of established
resolutions of The American Legion. The American Legion does not have a
resolution that addresses on-site regulated medical waste treatment
systems at certain Department of Veterans Affairs facilities. As a
large, grassroots organization, The American Legion takes positions on
legislation based on resolutions passed by our membership. With no
resolutions addressing the provisions of the legislation, The American
Legion is researching the material and working with our membership to
determine the course of action that best serves veterans.
The American Legion has no position on H.R. 5974.
Draft Bill
To amend title 38, United States Code, to improve the productivity
of the management of Department of Veterans Affairs health care, and
for other purposes.
The provisions in this bill fall outside the scope of established
resolutions of The American Legion. The American Legion does not have a
resolution that addresses this issue. As a large, grassroots
organization, The American Legion takes positions on legislation based
on resolutions passed by our membership. With no resolutions addressing
the provisions of the legislation, The American Legion is researching
the material and working with our membership to determine the course of
action that best serves veterans.
The American Legion has no position on the Draft Bill.
Conclusion
Chairman Dunn, Ranking Member Brownley and distinguished members of
this critical Committee, The American Legion thanks this Subcommittee
for the opportunity to elucidate the position of our 2 million veteran
members of this organization. For additional information regarding this
testimony, please contact Assistant Director of the Legislative
Division, Larry Lohmann, at (202) 861-2700 or [email protected].
Prepared Statement of Jeremy M. Villanueva
Mr. Chairman and Members of the Subcommittee:
Thank you for inviting DAV (Disabled American Veterans) to testify
at this legislative hearing of the Subcommittee on Health of the House
Veterans' Affairs Committee. As you know, DAV is a non-profit veterans
service organization comprised of more than one million wartime
service-disabled veterans that is dedicated to a single purpose:
empowering veterans to lead high-quality lives with respect and
dignity. DAV is pleased to offer our views on the bills under
consideration by the Subcommittee.
H.R. 2787, the Veterans-Specific Education for Tomorrow's Medical
Doctors Act or VET MD Act
H.R. 2787 would establish a three-year pilot project instituting a
clinical observation program for students enrolled in a ``pre-med'' or
science curriculum who plan to attend medical school. Students would
spend a certain number of hours observing a practicing physician to
expose the student to a variety of health care experiences. The pilot
would be established at no fewer than five Department of Veterans
Affairs (VA) medical centers. The goal of the pilot is to increase
awareness among America's future physicians related to veterans'
issues. It is also intended to raise cultural awareness and sensitivity
in addressing their specific health care concerns, as well as engender
interest in pursuing medical careers, in general, and particularly,
within the Department, in these students. Following the program,
participants would be asked to fill out a ``reflection'' survey,
developed by VA, about their experience.
Mr. Chairman, DAV has no resolution on the development of such a
program within VA, but believes the intent of this legislation is in
keeping with the goals of developing a more robust field of candidates
for medical professions employed by the VA and ensuring more medical
professionals in the community have some awareness and understanding of
veterans' unique medical issues. We therefore have no objection to this
legislation's favorable consideration.
H.R. 3696, the Wounded Warrior Workforce Enhancement Act
H.R. 3696 would require the VA Secretary to award grants to
educational institutions of $1 million to $1.5 million to create or
expand master's degree programs in orthotics and prosthetics. An
appropriation of $15 million would be made available through the end of
fiscal year (FY) 2020 with unexpended obligations returned to the U.S.
Treasury at that time. Initially, VA would be required to establish a
request for proposal for awarding these grants. Only educational
institutions that have accreditation by the National Commission of
Orthotic and Prosthetic Education and ones that demonstrate the ability
to meet accreditation requirements would be eligible to receive grants.
Priority for grants would be given to programs that establish clinical
rotations with the VA. The Secretary may also require an institution to
demonstrate its commitment to continue the program after the VA grant
expires. Finally, the bill would require the Secretary to award a grant
of $5 million to establish a Center of Excellence in Orthotic and
Prosthetic Education in the private sector.
DAV notes the need to develop additional orthotic and prosthetic
expertise in the private sector based on the Bureau of Labor Statistics
projection of a 22 percent growth in need for these professionals
between 2016 and 2026 due to the aging of ``baby boomers'' who are
prone to diabetes and cardiovascular conditions that may cause limb
loss and be in need of these specialized services.
However, the Veterans Health Administration (VHA) is not reporting
difficulty in recruiting or retaining orthotists and prosthetists and
notes its training capacity (about 20 residents in 2017) is adequate to
serve the needs of the Department. In contrast, the Department does
have notable shortages in medical officers, nurses, psychologists and
medical clerks. Dedicating $15 million to train students who will
primarily provide care to patients outside of VA may further impair
VHA's ability to hire more in demand care providers. Additionally, VA
currently has five centers of excellence in prosthetic research
associated with academic affiliates which creates a number of
opportunities for interns and students from affiliated institutions to
provide care to veterans in VA.
For these reasons, DAV is unable to support H.R. 3696 at this time.
H.R. 5521, the VA Hiring Enhancement Act
H.R. 5521, the VA Hiring Enhancement Act, would render ``non-
compete'' agreements between an applicant for VA employment and a
previous employer non-applicable with regard to VA employment.
Employees appointed with this understanding would be required to serve
out the length of their non-compete agreement within their VA position
or serve in that position for at least one year (whichever is longer).
The bill intends to allow VA, on a contingent basis, to begin
recruiting and hiring physicians up to two years before they complete
their residency, as well as physicians who have completed their
residencies leading to board certification. These contingent appointed
physicians must satisfy VA's requirements to receive a permanent
appointment.
DAV fully supports efforts to recruit, retain and develop a skilled
clinical workforce to meet the needs of veterans. We appreciate the
goal of this legislation aimed at creating as large an applicant pool
for qualified medical professionals to treat our service disabled
veterans as possible in VA. DAV Resolution No. 228 calls for effective
recruitment, retention and development of the VA health care workforce.
Because this measure attempts to reduce barriers for employment at VA
for physicians; we are pleased to support the bill's passage.
H.R. 5693, the Long-Term Care Veterans Choice Act
In accordance with DAV Resolution No. 227, calling for legislation
to improve the comprehensive program of long-term services and supports
for service-connected disabled veterans regardless of their disability
ratings, DAV supports this measure.
If enacted, this measure (H.R. 5693) would provide veterans who are
no longer capable of living independently an alternative to nursing
home care, in which the veteran would continue to receive the care that
they need in an intimate home-like environment through VA's Home-Based
Primary Care program, and the Medical Foster Home (MFH) attendant.
Medical Foster Homes are a type of Community Residential Care by which
veterans with serious chronic disabling conditions requiring nursing
home level care and coordination of services are able to receive these
services in a non-institutional setting. Patient participation in the
MFH program is voluntary and veteran residents report very high
satisfaction ratings.
Currently, the administrative costs for VA per veteran in the MFH
program, including the cost of Home Based Primary Care, medications and
supplies average less than $63 per day. However, veterans who qualify
for nursing home care fully paid for by the government, must pay the
full cost for room, board, and personal assistance out of their own
pocket, which averages to be about $110 per day to live in a MFH.
Veterans who wish to reside in a Medical Foster Home but are unable
to pay approximately $1,500 to $3,000 per month are not able to avail
themselves of this benefit, so many are placed in nursing homes at much
greater cost to VA. This measure would address this inequity by giving
VA a three-year authority to pay for veterans, who would qualify for
VA-paid nursing home care placement, so they can reside in a VA-
approved MFH.
As the veteran population continues to age, the need for long-term
care services will continue to grow. Home-based community programs like
MFHs will enable VA to meet the needs of aging veterans in a manner
closer to independent living than institutionalized care. With the
passage of this bill, veterans would have the option of care that more
closely aligns with their independence while maintaining their quality
of life.
H.R. 5864, to direct the Secretary of Veterans Affairs to establish
qualification for the human resources positions within the Veterans
Health Administration
H.R. 5864, the VA Hospitals Establishing Leadership Performance Act
would require the Secretary of Veterans Affairs to establish
qualifications and standardized performance metrics for each human
resources position within the Veterans Health Administration within 180
days of enactment. Upon establishing such qualifications and
standardized performance metrics for these positions, VA would be
required to submit a report to Congress. The Comptroller General would
then be required to submit a report describing implementation of the
qualifications and performance metrics and assess the quality of such
measures within 180 days.
DAV supports this legislation in accordance with DAV Resolution No.
228, which calls for a simple-to-administer alternative VHA personnel
system, in law and regulation, which governs all VHA employees, applies
best practices from the private sector to human capital management, and
supports pay and benefits that are competitive with the private sector
and DAV Resolution No. 221, which supports VA's use of meaningful and
clearly articulated measures to gauge employees' performance.
VA acknowledges the need for reforming its human capital management
system, but leadership has not always provided strong guidance,
oversight or resource support to carry out such reforms. VA's human
capital management is also hampered by the Department's current IT
systems that provide organizational data and by its real and perceived
need to comply with a collection of byzantine laws, regulations, and
internal policies that guide its functions.
In VA's latest Strategic Plan, it states: ``A robust human capital
management capability is paramount to VA's ability to effectively and
efficiently employ its workforce in service to Veterans.'' \1\ The plan
identifies several strategies to modernize its human capital management
capabilities objective including:
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\1\ Department of Veterans Affairs: Strategic Plan 2018-2024. P. 30
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1.Standardize Human Capital Policies Enterprise-wide
2.Improve Staffing to Ensure a Qualified VA Workforce is in Place
3.Improve Leadership and Workforce Competency
4.Institute Manpower Management to Optimize VA Human Capital
Resources
Many organizations have opined about improving VA's competency and
performance of human resources staff including the Commission on Care,
the Government Accountability Office and the CMS Alliance to Modernize
Healthcare Federally Funded Research and Development Center who
produced the Congressionally mandated Independent Assessment of the
Health Care Delivery Systems and Management Processes of the Department
of Veterans Affairs. All indicate that system-wide improvement requires
systemic change which would fundamentally alter the current operations,
leadership, and inputs (including informatics and policy guidance) of
the current human capital management system.
DAV believes H.R. 5864 offers a good starting point for the
fundamental overhaul of VA's human capital management system needed
within the Department, but it is just a start. While standardized
position descriptions with corresponding performance measures must be
developed, VA also needs to ensure that it streamlines and simplifies
policies surrounding such practices as recruitment and hiring. It must
create specialists within the system who are informed by best practices
in such functional areas as recruitment, retention, staff development,
employee benefits, and performance management as well as expertise in
important clinical staff professions such as doctors, nurses, allied
health professionals and clinical support staff.
As long as VA must work with four personnel hiring authorities,
each with its own requirements, specialists within VA's Central Office
or the VISN must understand the intricacies of each. These specialized
experts can serve as consultants to field level specialists who are
actually performing the functions. VA human resources professionals
will certainly require better informatics and many may require training
to overcome deficits in core competencies to meet the minimal
qualifications of new position descriptions. Most importantly, Human
Capital Management Reform will require a long-term commitment from VA's
leadership and Congress. The core position descriptions developed under
H.R. 5864 will not be valuable if VA is unable to hire or develop the
human talent necessary to fill these positions.
Congress should maintain oversight and continue to work on ways to
simplify personnel policies and procedures for the Department,
including working toward a system that administers personnel matters
under a single system and is driven by best practices within the
federal government and private sector. This will limit the need for
expertise in so many systems and may make VA more responsive to market
factors that affect hiring and retaining the best talent. Only when a
systemic approach to reform is taken, will VA be able to optimize human
capital management to identify more effective ways to use its scarcest
resource-well trained and compassionate people who effectively provide
care to our nation's veterans.
H.R. 5938, the Veterans Serving Veterans Act
This bill would establish a vacancy and recruitment database to
facilitate the recruitment of certain members of the Armed Forces to
satisfy the occupational needs of the VA and establish a training and
certification program for intermediate care technicians within the
Department. We support H.R. 5938 based on DAV Resolution No. 228, which
calls for effective recruitment, retention and development efforts
within VA.
This bill also recognizes the service member's military vocational
training as being valuable in the civilian workforce. DAV Resolution
No. 248 calls for the elimination of employment barriers that impede
the transfer of occupations to the civilian labor market. This bill is
in the spirit of that goal.
DAV and our Independent Budget (IB) partners have also urged
Congress to support improvements to the VA's human capital management
systems by providing the necessary funding and authorities to implement
system reform and for VA to utilize the broad-based recruitment and
employment incentives available in order to attract workforce talent
and to remain competitive in various workforce markets.
The IB partners acknowledge that VA's HR system is complicated and
therefore demands a holistic approach to workforce development that
allows VA to recruit, train, and retain a high-quality workforce of
talented and compassionate professionals capable of caring for our
veterans, while simultaneously ensuring that VA has the authority to
properly reward and hold employees accountable. This must include
acknowledging that employee experience is equally vital to its
transformation efforts. If Congress is intent on helping VA transform
its culture and workforce, we suggest the Department is provided the
leverage to hire employees more quickly and offer compensation that is
competitive and commensurate with their skill levels.
In addition, it should be noted that this bill could help the
transition process from military to civilian life, a process that can
be difficult for many separating service men and women. By allowing the
VHA to directly hire separating service members, it allows the
Department to inquire about an applicant's skills and qualifications
that would likely otherwise go unnoticed in the current process and
would provide the veteran employment from day one aiding in a
successful transition from military to civilian life.
With passage of this measure, Congress would ensure that the VA is
hiring highly skilled and culturally invested applicants and would
showcase the military as one of the nation's finest providers of
vocational training.
H.R. 5974: The VA COST SAVINGS Enhancement Act
The VA COST SAVINGS Enhancements Act would require VA to conduct a
cost analysis model to determine if the installation and use of an on-
site medical waste treatment system, in selected VA medical facilities,
will result in a cost-savings over a 5 year period.
Currently, biohazardous medical waste, specifically items
contaminated by body fluids and deemed potentially infectious, must be
disposed of off-site at specially designated regional disposal centers.
This bill proposes the use of on-site sterilization machines to compact
``red bag'' medical waste to destroy microbial life, thus rendering the
hazardous bio-waste material safe for routine disposal.
DAV does not have a resolution specific to this issue and takes no
position on the bill.
Draft bill, to improve the productivity and management of VA health
care facilities
This bill would amend current law requiring the VA Secretary, in
managing the VA health care system, to establish a new management
authority tracking relative value units (RVU) for all VA providers,
provide training for all VA providers on clinical procedure coding, and
establish performance standards to evaluate clinical productivity based
on nationally recognized RVUs for each profession and each VA medical
facility.
Public Law 107-135 mandated that VA establish a nationwide policy
to ensure medical facilities have adequate staff to provide
appropriate, high-quality care and services. In this regard, VA's
current policy outlines productivity and staffing for Specialty Group
Practice providers, Mental Health and Emergency Medicine. Of the total
RVU, which consists of three components: work performed (wRVU),
practice expense (peRVU), and malpractice (mpRVU) expense, VA's policy
on productivity measurement only uses wRVU, which is perhaps the best
known and most-often utilized RVU component. When VA specialty provider
group practices are out of production range for its specialty and peer
grouping, remediation plans are required to be developed, reviewed,
receive concurrence from leadership, and implemented to improve
specialty physician group practice productivity.
Previous testimony before this Subcommittee on factors affecting
clinical productivity noted the following:
1)The number of patients assigned to VHA general primary care
providers is 12 percent lower than the private sector benchmark for
patients of a similar acuity.
2)With respect to specialty providers, [ ] analysis shows that VHA
specialists are less productive than their private sector counterparts
on two industry measures - encounters and work relative value units
(wRVUs). Many specialties fall in the 50th percentile of private sector
providers; others are as low as the 25th percentile. However, when
encounters (visits) are used as a measure, the gap shrinks and VHA
specialty care compares more favorably to the private sector. In a
system as large and varied as VHA, we did find variation in the
relative productivity of providers. For instance, specialty care
providers at the most complex facilities were found to be more
productive than their peers, and the most productive VHA providers
(those at the 75th percentile of VHA providers) are often more
productive than the private sector. Mental health provider productivity
at VHA was calculated to be in the 100th and 72nd percentiles as
measured by both wRVUs and encounters, compared to industry benchmarks.
Because relative value units may not capture other factors that
impact health care productivity (compared to the private sector, VA
providers have a lower room-to-patient ratio and have significantly
fewer nurses and administrative support staff), we urge the
Subcommittee consider these proximate factors in requiring VA to track
productivity. VA's own management tool, the Specialty Productivity
Access Report and Quadrant, recognizes this in part by including some
support staff ratios in assessing productivity and staffing standards.
Supporting infrastructure issues are addressed in remediation plans.
Moreover, recognizing the methods to measure and determine
productivity, budgeting, allocating expenses, and cost benchmarking
continue to evolve, as well as VA's work to address four
recommendations in the June 23, 2017, Government Accountability Report,
we recommend the Subcommittee consider under paragraph 2 to include
subparagraph ``(c) other productivity measures and models determined
appropriate by the Secretary.''
Finally, we recommend the Subcommittee make clear whether the
remediation plan required by this bill is intended to affect the
remediation plan in Section 109 of S. 2372, the John S. McCain III,
Daniel K. Akaka, and Samuel R. Johnson VA Maintaining Internal Systems
and Strengthening Integrated Outside Networks Act of 2018 or the VA
MISSION Act of 2018.
Mr. Chairman, we must acknowledge that the VA health care system is
unlike most private sector health care systems in that its resources
are distributed by a capitation system to more equitably allocate funds
across a health care system that spans this nation and its territories.
While all funding models have strength and weaknesses, in a capitation
model there is strong incentive to conserve resources to focus more on
value than volume unlike fee schedule or other retrospective payment
models.
Policy proposals to manage inpatient and outpatient clinical
productivity in such a health care system must recognize and work
within these specific operating environments to achieve the appropriate
balance of efficiency and effectiveness while preserving the high
quality care VA provides to our nation's ill and injured veterans.
This concludes my testimony, Mr. Chairman. DAV would be pleased to
respond for the record to any questions from you or the Subcommittee
Members concerning our views on these bills.
Prepared Statement of Kayda Keleher
Chairman Wenstrup, Ranking Member Brownley, and members of the
Subcommittee, on behalf of the women and men of the Veterans of Foreign
Wars of the United States (VFW) and its Auxiliary, thank you for the
opportunity to provide our remarks on legislation pending before this
Subcommittee.
H.R. 2787, Veterans-Specific Education for Tomorrow's Medical Doctors
Act or the VET MD Act
The VFW supports the Veterans-Specific Education for Tomorrow's
Medical Doctors Act, with suggestions to improve the legislation. This
legislation would mandate VA carry out a pilot program at no less than
five Department of Veterans Affairs (VA) facilities to provide a
diverse selection of undergraduate students with clinical observation
experience. The goals of this clinical observation pilot would be to
increase awareness and knowledge of veterans' health care of future
medical professionals and increase the diversity of future medical
professionals.
While VA facilities across the country are already allowing
students to observe clinical hours, this program would be a practical
way to expand this practice. The VFW also finds it to be valuable that
the legislation includes consideration of areas with staffing shortages
within VA, in an attempt to hopefully later recruit new providers.
However, the VFW would find this to be more advantageous if the
language also included projected staffing shortages within VA. The VFW
suggests including veterans as a priority along with those who live in
an area with a shortage of health care professionals and/or are first
generation college students.
The VFW also suggests more precisely defining the term ``timely
manner'' under ``Other Matters'' regarding the notification to
Congress, as the term can be too loosely defined and may result in
Congress receiving notification at a much slower rate than intended.
Lastly, the VFW recommends including metrics to determine how many
students who took part in the program go on to a graduate medical
program for fields determined to have a staffing shortage within VA.
H.R. 3696, Wounded Warrior Workforce Enhancement Act
Section 2
The VFW agrees with the intent of this section, but cannot support
the language as written. This section would mandate that VA provide
grants to research programs with orthotic and prosthetics education
programs accredited by the National Commission on Orthotic and
Prosthetic Education in cooperation with the Commission on
Accreditation of Allied Health Education Programs.
One of VA's four statutory missions is to educate and train health
professionals to enhance the quality of care provided to veteran
patients within VA. This is accomplished through coordinated programs
and partnerships with affiliated academic institutions.
The Wounded Warrior Workforce Enhancement Act would not require any
form of partnership, yet would provide millions of dollars in grants
for non-VA institutions to expand, build, supplement salaries, provide
financial aid, or purchase equipment for graduate level orthotic and
prosthetics programs for very specifically defined institutions. While
the language does state that schools that are partnered with VA would
be prioritized for grants, and schools that apply must show a
willingness to participate; that is not enough. The VFW believes this
must be tied back to delivery of care for veteran patients within VA.
If VA is to fund grants such as this, veterans must see a positive
outcome from which they can benefit.
Section 3
The VFW opposes this section, which would require VA to provide a
grant to build a non-VA center of excellence for orthotics and
prosthetics at a graduate orthotic and prosthetics program accredited
by the National Commission on Orthotic and Prosthetic Education in
cooperation with the Commission on Accreditation of Allied Health
Education Programs. Aside from the same concerns as in Section 2
regarding the lack of partnership or contracts with VA, this section
would ultimately require VA to fund this non-VA entity that is not only
unnecessary as VA and the Department of Defense (DOD) lead the way in
orthotics and prosthetics, but would again have no direct tie to care
provided to veterans.
It is imperative that America's providers are able to treat
patients for orthotics and prosthetics. There are currently five
Polytrauma Rehabilitation Centers and 21 Polytrauma Network Sites
within VA--that does not include the Polytrauma Support Clinic Teams,
Polytrauma Points of Contact or Department of Defense prosthetic
centers of excellence and other clinics. With this in mind, the VFW
cannot justify outsourcing valuable VA resources to bolster a non-VA
entity that would not benefit veterans. The grant for this program,
which would be substantial, would again be eligible for use toward
training, salary supplementation, financial aid, building renovations
and equipment purchases.
H.R. 5521, VA Hiring Enhancement Act
Section 2
The VFW supports this section which would remove barriers for
employment of health care providers who were required to sign a non-
compete contract with previous employers. By removing this barrier more
medical professionals who want to treat veterans would be able to
pursue a career at VA medical facilities.
Section 3
This section would require VA to hire health care providers who are
board eligible. The Choice Act required VA's Office of Inspector
General to annually determine the top five hiring shortages. Since this
enactment in 2014, medical officers have been ranked as the number one
staffing need within VA. With nearly 38,000 current job vacancies
within VA, the VFW cannot support limiting VA's hiring pool.
As determined by studies such as Comparing VA and Non-VA Quality of
Care: A Systematic Review, published by the RAND Corporation in the
Journal of General Internal Medicine, 2016, VA either outperforms or
performs on par with non-VA care. So while this legislation is intended
to limit applications to the most highly qualified, the VFW feels this
is not a necessary precaution at this time.
Lastly, this section's attempt to provide VA the authority to hire
residents is redundant with current law. In Section 206 of VA Choice
and Quality Employment Act of 2017 the secretary received authority to
hire students and recent graduates.
H.R. 5693, Long-Term Care Veterans Choice Act
The VFW supports this legislation which would authorize VA to enter
into contract agreements for non-VA medical foster homes. By expanding
this option of long-term care to veterans who are unable to live
independently but do not want to be institutionalized, Congress would
be providing veterans with the ability to receive the care they need
while also maintaining a higher quality of life. The VFW urges Congress
to pass this legislation, which would provide more options for veterans
to decide what form of long-term care is right for them.
H.R. 5864, VA Hospitals Establishing Leadership Performance Act
The VFW supports this legislation which would establish
qualifications for human resources positions within the Veterans Health
Administration. In doing so, this legislation would assure standardized
performance metrics and require VA to report the established
qualifications and metrics, as well as the implementation and quality
of the metrics.
H.R. 5938, Veterans Serving Veterans Act of 2018
The VFW agrees with the intent of this draft legislation, but has
very serious concerns with its impact on privacy. This draft
legislation would establish a vacancy and recruitment database to
facilitate recruitment of members of the armed forces to fill open
positions within VA.
Requiring VA and DOD to work together to establish a functional and
correct database of individuals actively serving in the military with
military occupational specialties that would link individuals with
corresponding vacant positions within VA, would require excessive
amounts of time, funding and technology. While the desired goal of
filling desperately needed positions is commendable, establishing a
database is neither realistic nor the right way to do it.
The VFW also has concern with how this legislation would allow
those in the armed forces to elect not to be listed in the database,
but requires the member to submit this request in writing with no other
options or outreach directive to assure they are properly notified of
this option. Once on the list, the secretary of VA would have authority
to determine who within the department has access to the information.
These options are listed as offices, officials and employees. The VFW
believes that VA must be more selective with who has access to the
name, contact information and other personal information of
transitioning service members.
H.R. 5974, Department of Veterans Affairs Creation of On-Site Treatment
Systems Affording Veterans Improvements and Numerous General Safety
Enhancements Act
The VFW supports this legislation which would direct VA to use on-
site regulated medical waste treatment systems. At this point in time,
most VA facilities are contracting out medical and biohazardous waste
disposal. These contracts come with a high price tag and require the
transportation of infectious waste such as blood, microbiological
cultures, body parts, used dressings and more. In areas where it would
result in cost savings, there is absolutely no reason why VA should not
be discarding their own medical waste instead of using contractors.
Draft Legislation to improve productivity of the management of
Department of Veterans Affairs health care, and for other purposes.
The VFW agrees with the intent of this draft legislation but has
some concerns that must be addressed before we are able to support.
This legislation would require VA to reports its relative value units
(RVUs). RVUs are a national standard used for determining budget,
expenses, cost benchmarking and productivity, which was first
introduced by the American health care systems by Centers for Medicare
and Medicaid Services in 1992. While the private sector has found RVUs
to be statistically reliable, they are at times flawed - and
predominantly used to determine provider payments.
There would most certainly be value to tracking RVUs and the levels
of productivity within VA. The VFW believes it would provide data
showcasing that as funding increases within VA, so does productivity.
With this said, there are still concerns regarding comparison to the
private sector and maintaining the level of care that veterans prefer.
The private sector is not required to make data publicly available
the way VA is required, which at times causes an unsettling double
standard. VFW members report in surveys time and time again that one of
the reasons they prefer VA is due to increased face time with their
providers. VA providers typically spend more time with patients, which
leads to higher patient satisfaction and better quality care. Veteran
patients who use VA are also statistically sicker than patients who do
not use VA. This requires more time between patients and their
providers. These and other factors are not reflected in RVUs. The VFW
is grateful this legislation would take into account non-clinical
duties, as VA providers conduct more research and training than private
sector providers. However, the VFW would like to know how Congress
intends to use RVUs before supporting this bill. The VFW warns against
basing legislation or appropriations on how VA RVUs compare to private
sector RVUs. Doing so would fail veterans and the system specifically
created to meet their health care needs.
Mr. Chairman, this concludes my testimony. I am prepared to take
any questions you or the Subcommittee members may have.
Prepared Statement of Jessica Bonjorni
Good morning Chairman Dunn, Ranking Member Brownley, and Members of
the Subcommittee. I appreciate the opportunity to discuss the
Department of Veterans Affairs' (VA) views on pending legislation,
including H.R. 2787, H.R. 3696, H.R. 5521, H.R. 5693, H.R. 5864, and
two draft bills related to the Veterans Serving Veterans Act and the
improvement of VHA productivity and efficiency. Due to the delay in
notification regarding the draft ``VA COST SAVINGS Enhancements Act'',
we are unable to provide views on that bill at this time, but will
follow up with the Committee as soon as possible. I am accompanied
today by Ms. Dayna Cooper, Director, Home and Community-Based Programs,
Veterans Health Administration.
H.R. 2787: Vet MD Act
The VA supports the intent of this bill to develop a nation-wide
pre-health shadowing program within VA for undergraduate students who
want to have a healthcare career. This bill, H.R. 2787, is an almost
exact duplicate of H.R. 6187 from 2016. At that time, VA worked on
extensive technical assists to improve the bill, improving the
likelihood it could be implemented easily and at the lowest cost within
VA. Unfortunately, the new bill contains nearly all the same technical
limitations of H.R. 6187 and does not reflect prior feedback.
The bill focuses on pre-medical students to the exclusion of all
other health occupations. VA has previously advised that the bill
should apply to all pre-health students and include both undergraduate
students and post-baccalaureate students, since all such students
already display a high level of interest in pursuing a health career.
The bill describes a three-year pilot program that would start no
later than August 15, 2020. Unfortunately, this program would require
VA to promulgate regulations and depending on the bill passage, that
start date would be very challenging to meet. The bill also requires
surveys of all participants both pre- and post- observation, curriculum
development at all sites to ensure a standardized experience, and
18,000 observation hours within VA clinical sites (5 centers x 20
students/center x 60 hours of observation, repeated three times a
year).
One of the largest technical hurdles to the bill is the requirement
to have an applicant online portal developed to take student
applications. The USAJOBS/USA Staffing system could be used for this
initiative, but it would require customization of the applicant system
for these student observers. On the other hand, to alleviate the time-
intensive and therefore costly applicant selection process, VA has
previously recommended using the Deans' offices of VA-affiliated
educational institutions to provide applicant reference letters and to
screen applicants rather than hosting an applicant portal by whichever
Information Technology (IT) mechanism is least costly.
The bill essentially requires VA to act as an educational
institution by creating ``standardized application, assessment,
selection and processing requirements.'' VA does not believe that it
should independently develop a student applicant rating and ranking
system, but rather should rely on pre-health advisors at affiliated
institutions to refer best qualified candidates.
The Congressional notification requirements include notifying
Congress of sites chosen in a timely manner. The reporting burden is
significant, and includes, not later than 60 days before completion of
the three-year pilot, reporting on the number and demographics of all
applicants, selectees, and all that completed the program, and before
and after participant survey results.
For the bill as written, the expected timeline would be as follows:
Fiscal Year (FY) 2019 - Bill passes; staff recruitment
process begins. IT dollars for customization of applicant portal in USA
Jobs/USA Staffing awarded;
FY 2020 - Staff hired mid-way through year (1/2 salary
support). Regulation development begins. Customization of USA Jobs/USA
Staffing begun;
FY 2021 - Regulations completed. Applicant portal
completed. RFP process begins and ends for medical center sites. Sites
recruit for and hire GS-12 Site Coordinators;
FY 2022 - Pilot begins;
FY 2023 - Second year of pilot starts;
FY 2024 - Third year of pilot starts;
FY 2025 - Pilot ends; Evaluation and analysis begin;
FY 2026 - VA staff complete work including Congressional
report and are re-assigned if initiative is not authorized to continue.
VA would require major staff support to implement this bill as
written. We assume one Nurse IV Program Manager, one General Schedule
(GS)-14 Management Analyst, one GS-13 Education Program Specialist, and
one GS-11 Staff Assistant to manage this program. We also assume a GS-
12 site coordinator at each of the five medical centers starting in
2021 after the sites are chosen. We assume that in FY 2020 we incur
half the cost of VA Full-time Equivalent (FTE) due to recruitment
delays. In addition, we would require IT dollars to modify the USAJOBS
/ USA Staffing system for customization for this initiative over a two-
year period.
We estimate the total cost of this bill as follows: $436,453 One
Year Total; $7,068,192 Five Year Total; and $9,363,343 Ten Year Total.
H.R. 3696: Wounded Warrior Workforce Enhancement Act
Two sections of this bill call for establishing new or expanding
existing prosthetic/orthotic graduate programs (total limit of $15
million and site limit of $1.5 million), and the establishment of one
prosthetic/orthotic research Center of Excellence (CoE) ($5 million).
Section 2 of the bill requires the expansion of prosthetic/orthotic
graduate programs.
VA does not support this bill because VA already provides
rehabilitation services to Veterans with a mix of providers, including
physical medicine and rehabilitation physicians, physical therapists,
occupational therapists, prosthetists and orthotists, all of whom work
with the Veteran to enable the best possible rehabilitation given the
individual's needs. VA offers in-house orthotic and prosthetic services
at 84 laboratories across VA; in addition, VA contracts with more than
600 vendors for specialized orthotic and prosthetic services. Through
both in-house staffing and contractual arrangements, VA is able to
provide state-of-the-art commercially available items ranging from
advanced myoelectric prosthetic arms to specific custom fitted
orthoses.
Nationally, VA has approximately 340 clinical orthotic and
prosthetic staff. VA offers one of the largest orthotic and prosthetic
residency programs in the nation. In FY 2017, VA's Office of Academic
Affiliations allocated $894,838 to support 20 Orthotics/Prosthetics
residents at 13 Veterans Affairs Medical Centers. The training consists
of a yearlong post-master's residency, with an average stipend of
$44,000 per trainee. In recent years, VA has expanded the number of
training sites and the number of trainees. From this pool of advanced
trainees, we are able to employ orthotists and prosthetists without the
burden of supporting trainees though their full graduate training.
Much of the specialized orthotic and prosthetic capacity of VA is
met through contract mechanisms. Direct grants to schools to start or
expand masters or doctoral training programs would serve the private
sector rather than VA or Veterans. VA does not currently serve as a
granting authority for educational programs, and therefore VA does not
presently have regulations which would oversee these activities.
Rather, VA provides focused clinical practica at or near the end of
formal training. This bill would establish a precedent for other
educational institutions to receive grant funds to establish or enhance
their own educational programs with no clear-cut benefit or linkage to
VA's needs. In the future, Congress and VA might be pressured to
provide grants to educational institutions for an additional 40 health
professions.
Section 3 of the bill would require VA to award a grant to an
eligible institution to enable that institution to establish a CoE in
Orthotic and Prosthetic Education and enable that institution to
improve orthotic and prosthetic outcomes for Veterans, Service members,
and civilians by conducting evidence-based research. VA would be
required to give priority in the award of a grant to an eligible
institution that has in force, or demonstrates the willingness and
ability to enter into, a Memorandum of Understanding (MOU) with VA, the
Department of Defense (DoD), or another appropriate Federal agency, or
a cooperative agreement with an appropriate private sector entity that
provides for the provision of resources to the Center and assistance to
the Center in conducting research and disseminating the results of such
research. The grant awarded under this section could not exceed $5
million. Within 90 days of the date of the enactment of this Act, VA
would have to issue a request for proposals from eligible institutions
for the grant available under this section. The grantee would be
required to use the grant to develop an agenda for orthotics and
prosthetics education research, fund research in orthotics and
prosthetics education, and publish or otherwise disseminate research
findings relating to orthotics and prosthetics education. The grantee
could use the funds of the grant for a period of 5 years from the date
of the award of the grant. To be eligible for the grant, an institution
would have to: have a robust research program; offer an orthotics and
prosthetics education program accredited by the National Commission on
Orthotic and Prosthetic Education in cooperation with the Commission on
Accreditation of Allied Health Education Programs; be well recognized
in the field of orthotics and prosthetics education; and have an
established association with a VA medical center or clinic and a local
rehabilitation hospital. There would be authorized to be appropriated
for fiscal year 2018 $5 million to carry out this section.
VA does not support section 3 because we do not believe that a new
Center is necessary. DoD has an Extremity Trauma and Amputation Center
of Excellence, and VA and DoD work closely to provide care and conduct
scientific research to minimize the effect of traumatic injuries and
improve outcomes of wounded Veterans suffering from traumatic injury.
VA is already a world leader in prosthetics/orthotics research. VA has
five Rehabilitation Research and Development Centers that conduct
research related to prosthetic and orthotic interventions, amputation,
and restoration of function following trauma:
1. Center for Limb Loss Prevention and Prosthetic Engineering in
Seattle, WA.
2. Center for Wheelchairs and Associated Rehabilitation Engineering
in Pittsburgh, PA.
3. Center for Functional Electrical Stimulation in Cleveland, OH.
4. Center for Advanced Platform Technology in Cleveland, OH.
5. Center for Neurorestoration and Neurotechnology in Providence,
RI.
These Centers provide a rich scientific environment in which
clinicians work closely with researchers to improve and enhance care.
They are not positioned to confer terminal degrees for prosthetic and
orthotic care/research, but they are engaged in training and mentoring
clinicians and engineers to develop lines of inquiry that will have a
positive impact on amputee care. Moreover, VA would not have oversight
of the Center.
VA is already investing a great deal into advancing prosthetic
technology, and these Centers incorporate our interns and residents as
well as graduate students from affiliated academic institutions. Each
Center is funded with a base budget of nearly $1 million, but they are
further required to seek VA or agency research funding. With these
Centers and staffing in place, VA is additionally bringing in grants of
approximately $10 million per year. As VA has already established
internal research resources in this domain, the value to VA and
Veterans for establishing a sixth non-VA research center does not seem
warranted.
Finally, we believe the requirement to issue a request for
proposals (RFP) within 90 days of enactment would be very difficult to
meet as VA would first need to promulgate regulations prior to being
able to issue the RFP.
We note that the language in section 3(a)(2), regarding how VA
would give priority in the award of a grant, refers to at least some
types of arrangements that could not exist. For example, VA does not
have legal authority to enter into an MOU for the provision of
resources, whether in cash or in-kind, to an institution; similarly, we
are unsure as to whether the bill means to refer to a ``cooperative
agreement'', as that term is used in Federal procurement, but we would
appreciate the opportunity to discuss this further with the Committee.
We would be happy to work with the Committee to revise this language to
reflect the intended effect.
When considering implementation, VA provides the following training
proposal assumptions:
Enabling regulations would be developed and published
within the first two FYs;
Legal clarification between ``grants'' and the prescribed
``RFP'' methodology is achieved;
Sufficient interest from accredited schools of Orthotics/
Prosthetics;
Sufficient VA staff hired to plan, execute and monitor
the program;
Contracting to support program and evaluation services to
assess quality of the two components of this initiative;
The proposal mentions an implementation in the current
FY. We assume this is referring to the year this bill is passed, 2019
or later; and
While the bill does not state the desired number of
programs, with a site limit of $1.5 million and an overall cap of $15
million, this would cap the program at eight facilities, with
additional funding being used for program administration.
Regarding the research proposal, VA provides the following
assumptions:
VA would develop and publish enabling regulations in the
first two years FY 2019-2020;
Staff would begin reaching out to potential academic
partners;
A quality assessment plan for both programs would be
established and periodic site visitation would be conducted;
During FY 2020, the RFPs for academic programs (up to 8
sites) would be developed, released, and an expert peer-review panel
would make funding recommendations. Awards would be distributed in FY
2021;
Enabling regulations would be developed and published
within the first two fiscal years; and
In 2020, the RFP for the Research CoE (one site) would be
developed, released, and an expert peer-review panel would make the
funding recommendation, with funds to be distributed in 2021.
We estimate the total cost of this bill as follows: $183,811 One
Year Total and $20,604,079 Five/Ten Year Total.
H.R. 5521: VA Hiring Enhancement Act
Section 2 of this bill would amend title 38, United States Code, to
restrict the applicability of non-VA covenants not to compete to the
appointment of certain VHA personnel, specifically those appointed
under 38 U.S.C. Section 7401. Section 2 would further require an
individual appointed to such a position to agree to provide clinical
services at VA for a duration beginning from the date of their
appointment and ending on the latter of either one year after the date
of appointment, or the termination date of any covenant not to compete
that was entered into between the individual and the non-VA facility.
The Secretary would have the authority to waive this particular
requirement.
VA has concerns with section 2 of this proposed bill and requests
the opportunity to discuss the bill further with the Committee.
Section 3 of the bill would permit VHA to make a contingent
appointment as a VHA physician on the basis of the physician completing
their residency training.
VA also has concerns with this section and requests an opportunity
to further discuss. With regard to section 3, VA recommends removing
the language regarding the completion of a residency leading to board
eligibility, subsection (b)(1)(B)(i), since the requirement for
residency training is provided in the published Department of Veterans
Affairs (VA) physician qualification standard (VA Handbook 5005, Part
II, Appendix G2). Physicians must have completed residency training or
its equivalent, approved by the Secretary of VA in an accredited core
specialty training program leading to eligibility for board
certification. Approved residencies are:
Those approved by the accrediting bodies for graduate
medical education, the Accreditation Council for Graduate Medical
Education (ACGME) or American Osteopathic Association (AOA), in the
list published for the year the residency was completed, or
Other residencies or their equivalents which the local
Professional Standards Board determines to have provided an applicant
with appropriate professional training. The qualification standard also
allows for facilities to require VA physicians involved in academic
training programs to be board certified for faculty status.
VA also recommends removing the language regarding an offer for an
appointment on a contingent basis, subsection (b)(1)(B)(ii), since VA
may currently provide job offers to physicians pending completion of
residency training. There are no restrictions in statute or VA policy
on making job offers contingent upon completing residency training and
meeting other requirements for appointments as physicians within VHA.
If this needs to be clarified in statute, VA suggests including the
information in a new subsection (h) as follows: Section 7402 of title
38, United States Code, is amended by adding at the end the following
subsection (h): ``(h) The Secretary may provide job offers to
physicians pending completion of residency training programs and
completing the requirements for appointments under subsection (b) by
not later than two years after the date of the job offer.''
At this time, VA does not have a cost estimate for this bill.
H.R. 5693: Long-Term Care Veterans Choice Act
H.R. 5693, the Long-Term Care Veterans Choice Act, would amend
section 1720 of title 38 U.S.C. to add a new subsection (h) providing
authority for the Secretary to pay for long-term care for certain
Veterans in medical foster homes (MFH) that meet Department standards.
Specifically, the draft bill would allow Veterans, for whom VA is
required by law to offer to purchase or provide nursing home care, to
be offered placement in homes designed to provide non-institutional
long-term supportive care for Veterans who are unable to live
independently and prefer to live in a family setting. VA would pay MFH
expenses by a contract or agreement with the home. VA would be limited
to furnishing care and services to no more than 900 veterans placed in
a medical foster home before or after the date of the enactment of this
subsection. One condition of providing support for care in a MFH would
be the Veteran's agreement to accept home health care services
furnished by VA.
VA endorses the concept of using MFHs for Veterans who meet the
appropriateness criteria to receive such care in a more personal home
setting. VA endorsed this idea in its Fiscal Year (FY) 2018 and 2019
budget submissions and appreciates the Committee's consideration of
this concept. Our experience has shown that VA-approved MFHs can offer
safe, highly Veteran-centric care that is preferred by many Veterans at
a lower cost than traditional nursing home care. VA currently manages
the MFH program at over two-thirds of our medical centers; partnering
with homes in the community to provide care to nearly 1,000 Veterans
every day. Our experience also shows that MFHs can be used to increase
access and promote Veteran choice-of-care options.
While VA fully supports the MFH concept, we would look forward to
working with you to resolve a few technical issues in this bill. For
example, the limitation in proposed subsection (h)(2), regarding a
limit of 900 Veterans receiving care, is ambiguous; it is unclear
whether this is intended to be an average daily census limitation, or
if this is intended to be a hard cap on the total number of Veterans
who could receive care under this program during the entire 3-year
period. Moreover, while VA currently provides care through MFHs to
approximately 1,000 Veterans, most of these are not Veterans who would
qualify for care under section 1710A of title 38. Another change we
recommend is to revise the language in subsection (h)(1) to refer to
``contracts, agreements, or other arrangements.'' VA would like to work
with the Committee to ensure VA can effectively incorporate MFHs into
the continuum of authorized long-term services and support available to
Veterans. We are happy to provide the Committee with technical
assistance on this matter and are available for further discussion.
VHA estimates that, if enacted, this bill would cost $37.2 million
in FY 2019, $50.64 million in FY 2020, and a total of $150.2 million
over three years. Additionally, this bill could potentially divert
approximately $24.47 million in FY 2019, $33.34 million in FY 2020, and
a total of $98.90 million over 3 years from VA nursing home care costs,
depending on whether those beds are backfilled.
H.R. 5864: VA Hospitals Establishing Leadership Performance Act (``VA
HELP Act'')
This bill proposes to standardize qualification requirements and
performance metrics for human resources positions.
VA does not support the intent of this bill, but does support
efforts to modernize and professionalize the HR function throughout the
Government, including addressing the special needs of agencies that
employ physicians and other clinical professionals. The Human Resources
Management - GS-0200 series is under Title 5 and as such, is covered by
the Office of Personnel Management's (OPM) General Schedule
Qualification standards. These standards are broadly written for
Government-wide application and are not intended to provide detailed
information about specific qualification requirements for individual
positions at a particular agency. The HR occupation remains on the
Government Accountability Office's high risk list and have been
identified as a skills gap. To address this issue, OPM currently is
developing competencies for each HR specialty, and these competencies
will be linked with training. In addition, as part of the President's
Management Agenda, OPM will review and develop competency-based
standards for the HR occupation, and these standards also will be used
Government-wide. VA would support OPM addressing the issue across the
federal government by creating higher standards for the HR Specialists,
as government-wide surveys have found federal managers express the
lowest satisfaction with the quality of their HR services, more than
any other mission-support function.
It is important to note that all Federal agencies use OPM-approved
qualification standards, and creating VA specific standards would
negatively impact VA's ability to retain current staff, as well as to
recruit human resources (HR) professionals from other Federal agencies.
OPM states that such information (i.e., a description of any
specialized experience requirements that an agency may deem necessary
for a particular position) should be included in the vacancy
announcements issued by the agency. As such, rather than standardized
qualification requirements across VA, individual vacancy announcements
are customized to reflect the specialized experience (qualification
requirements) for the particular position itself. VA already utilizes
this method of applying specialized qualification requirements in all
HR job announcements. Additionally, performance standards are developed
on an annual basis for each HR position in the Department. These
performance standards are aligned with the specific functions and
specialized area of HR being performed by each HR professional.
While VA does not support the bill as written, if a decision is
made to proceed with the bill, VA requests the opportunity to meet with
the Committee to propose revisions to the language to address our
concerns. A few examples include:
Clearly define references to ``each human resources
position'' to identify occupation specific series.
The GS-200 Human Resources Management series currently
has numerous individual occupational series and title codes, of which
many have varying specialized experience requirements;
Revise references to VHA throughout the bill to reflect
VA is not limiting applicability to VHA.
Should this bill be revised as suggested, we would convene a
workgroup led by the Office of Human Resources and Administration and
would include subject matter experts (SMEs) from the three VA
administrations. This workgroup would meet regularly and would be
similar to the SME workgroups currently working on the development of
new Hybrid Title 38 qualification standards. The review and proposed
revisions would potentially take less than one year to complete. No new
FTE would be required. The VA anticipates minimal cost to the
Department if this bill is passed with suggested revisions.
H.R. 5938: Veterans Serving Veterans Act of 2018
Efforts are already underway to target transitioning military
members for mission critical and difficult to fill positions by
utilizing data contained in the Veterans Affairs/Department of Defense
Identity Repository (VADIR) database. Directly targeting transitioning
service members for mission critical and hard to fill VA positions
should result in more transitioning military members choosing to work
for VA and serve as a pipeline to fill critical vacancies. That said,
because of the level of coordination required with DoD, VA requests
that the bill be amended to require an implementation plan within 180
days, instead of requiring the establishment of a database within that
timeframe. Additionally, the Administration requests that the Act be
extended Government-wide. Leveraging this effort would both support
efforts to hire more veterans into Government, and assist agencies that
face similar hiring barriers.
An Intermediate Care Technician (ICT) training program has already
been implemented at 23 VA Medical Centers (VAMC) with ICTs on staff. We
are currently pursuing the establishment of an ICT Program at
additional VAMC locations which will meet the requirements outlined in
the bill. The ICT program has been considering the creation of
``centers'' at medical facilities to train and certify Veterans to work
as ICTs. The ICT program is currently evaluating whether to designate
one (or two) VAMCs as VA National ICT Training sites. These sites would
be utilized as the entry point for all VA-hired ICTs. After completing
a prescribed training curriculum, the ICTs would then proceed to the
VAMC that hired them. The ICT program is considering the elements
listed in the proposed bill when evaluating a possible National ICT
Training site, including the experience and success of VAMCs in
training ICTs and resource support for the ICTs or the ICT program at
individual VAMCs.
The estimated costs do not include the cost of hiring and training
an ICT, since that will depend on geographic location and the number of
ICTs hired by each VAMC. With that in mind, we estimate the total cost
of this bill as follows: $220 thousand in FY 2020 Total; $598 thousand
over five years; and $1.2 million over 10 years.
Draft Bill to Improve the Productivity of VA Health Care
This bill calls for VA to track relative value unit production
standards; requires all Department providers to attend training on
clinical procedure coding; mandates establishment of standardized
performance standards based on nationally recognized relative value
unit production standards; and requires submission of a report on the
implementation of the bill's requirements.
VA does not support this bill as written, and would like to discuss
the bill with the Committee to further refine the language. In support
of VA's position, it should be noted that VA already tracks relative
value units for Department Providers (Licensed Independent Providers
(LIP) as defined by the bill). A six-module online training program in
Clinical Procedure Coding is in development with a target release date
of late FY 2018. VA is concerned about the implementation of this
component in that the time required to train providers in coding will
significantly reduce their availability to provide timely health care
to Veterans.
Additionally, requiring LIPs to learn and become proficient in
skills not essential to direct patient care will have a detrimental
impact on the timely delivery of health care. VA is also concerned
about whether mandatory training of providers is the most effective and
efficient means to create system improvements. Also, VA has performance
standards in place, broken out by provider type and location. Specialty
specific productivity targets are established and are reviewed annually
at a minimum. Remediation plans are developed for provider practices
that do not meet minimum thresholds. Lastly, VA currently has the tools
in place to create the required report.
Pending VA meeting with the Committee to further discuss the coding
training requirement for LIPs, VA is not able to accurately develop
costs. Primary topics impacting the cost estimate include:
Determining the number of LIPs who would be impacted.
The time LIPs would be taken away from direct patient
care, and
Determining the number of Contract LIPs who would be
needed to fill the gap created when providers are required to use duty
hours to attend extensive training.
Mr. Chairman, this concludes my testimony. My colleagues and I are
prepared to answer any questions the Subcommittee may have.
Statements For The Record
AMERICAN FEDERATION OF GOVERNMENT EMPLOYEES, AFL-CIO
Chairman Wenstrup, Ranking Member Brownley and Members of the
Subcommittee:
The American Federation of Government Employees, AFL-CIO (AFGE) and
its National Veterans Affairs Council (NVAC) appreciate the opportunity
to submit a statement for the record on pending legislation.
AFGE represents nearly 700,000 federal employees, including 250,000
front-line employees at the Department of Veterans Affairs (VA)
providing medical care, mental health treatment and other essential
services to our nation's veterans.
H.R. 6066, To improve productivity of the management of Department of
Veterans Affairs health care, and for other purposes
AFGE and NVAC strongly oppose expanding management authority to
measure VA provider productivity through relative value units (RVUs).
RVUs fail to measure the many essential services that bring value to
the VA's mission of treating the complex needs of our wounded warriors,
including coordination of care, clinical research, palliative care,
triage, clinician training, dietary counseling, chemotherapy teaching,
and pre-op and post-op care among many other routine VA medical center
activities.
This bill ignores that far greater urgency of filling the thousands
of unfilled VA provider positions that have placed VA providers under
tremendous pressure to care for veterans with complex needs while
operating with excessive panel sizes, large numbers of unassigned
patients, and daily additional responsibilities such as responding to
computer view alerts and following up on lab reports.
In addition, as GAO noted in its May 2017 report on clinical
productivity and efficiency (GAO-17-480), VA could achieve significant
increases in productivity through the hiring of additional support
staff and improved infrastructure including both exam and procedure
rooms and adequately equipped facilities.
In the words of one of our discouraged VA front line physicians
``When RVUs are applied to physicians it places quantity over quality
of care. People are not widgets and the principles of mass production
should not be applied to patient care or we unduly increase the risk of
adverse patient outcomes''.
Veterans using the VA deserve better. Only the VA provides them
with adequate time to be properly diagnosed, treated, and referred to
the appropriate additional care. RVUs were designed for for-profit
health care and have absolutely no place in the VA health care system.
As another frontline clinician commented, ``Billing codes and encounter
codes don't capture the veteran's care accurately. You can't quantify
this unique type of care with coding.''
Furthermore, the unilateral use of RVUs to measure VA in-house
provider productivity would exacerbate the double standard already in
place that fails to measure the quality and access of private sector
care, thus depriving veterans of making an informed decision about
whether to seek care in the VA or use a Choice provider.
H.R. 2787, the Veterans-Specific Education for Tomorrow's Medical
Doctors Act
AFGE supports H.R. 2787. This bill would increase opportunities for
pre-medical undergraduate students to gain clinical observation
experiences at VA medical facilities. The intent of the bill is to
expose future physicians to veteran-centric care, increase the
diversity of the medical profession and address the nation's physician
shortage. AFGE supports H.R. 2787.
H.R. 3696, the Wounded Warrior Workforce Enhancement Act
AFGE and NVAC take no position on H.R. 3696, a bill to award
educational grants to expand master's degree programs in orthotics and
prosthetics.
H.R. 5521, the VA Hiring Enhancement Act
AFGE and NVAC take no position on H.R. 5521, a bill that would make
preexisting non-compete clauses nonapplicable to VA health care
personnel appointed under Title 38, and that would authorize physician
appointments on a contingent basis prior to the completion of medical
training.
H.R. 5693, the Long-Term Care Veterans Choice Act
AFGE and NVAC take no position on this bill on medical foster
homes.
H.R. 5864, the VA Hospitals Establishing Leadership Performance Act
AFGE and NVAC support this bill to establish standards and
performance measures for all Veterans Health Administration human
resources (HR) positions, but we also urge additional training and
modernization of the Department's HR workforce to reduce the widespread
violation of workplace rights and compensation laws applicable to VA
employees.
H.R. 5938, the Veterans Serving Veterans Act of 2018
AFGE and NVAC take no position on this bill expanding VA job
opportunities for active duty personnel.
H.R. 5974, the Department of Veterans Affairs Creation of On-Site
Treatment Systems Affording Veterans Improvements and Numerous
General Safety Enhancements Act
AFGE and NVAC take no position on this bill on VA medical waste
treatment systems but commends the intent of the bill to reduce costs
by taking steps to insource this function back to VA medical centers
and reduce reliance on costly contractors.
Thank you.
AMERICAN ORTHOTICS AND PROSTHETICS ASSOCIATION
Chairman Dunn, Ranking Member Brownley, and Members of the
Committee,
Thank you for inviting the American Orthotic and Prosthetic
Association to offer its perspective on the need to expand our pool of
highly educated clinicians who can offer prosthetic and orthotic care
to Wounded Warriors who have lost limbs or sustained chronic limb
impairment on the battlefield. We thank you for including HR 3696, the
Wounded Warrior Workforce Enhancement Act, in this hearing.
AOPA represents over 2,000 orthotic and prosthetic patient care
facilities and suppliers that evaluate patients for and design,
fabricate, fit, adjust and supervise the use of orthoses and
prostheses. Our members serve Veterans and civilians in the communities
where they live, and our goal is to ensure that every patient has
access to the highest standard of O&P care from a well-trained
clinician. It is not widely known that 80-90% of prosthetic/orthotic
care delivered to Veterans is provided in a community-based setting,
outside the walls of a VA Medical Center. The vast majority of your
constituents who are Veterans and who need a prosthesis or orthosis
received a device that was provided and maintained by an AOPA member.
The VA contracts with community-based providers to offer Veterans
timely, convenient and high quality prosthetic and orthotic care near
the locations where they live and work. Because such a high percentage
of care is delivered by community-based providers, the private sector
workforce and procurement relationships with the VA must be a part of
any discussion of lower extremity prosthetic and orthotic care for
Veterans.
Wounded Warriors Need Orthotic and Prosthetic Care
Traumatic Brain Injury (TBI) and amputation are signature injuries
of the wars in Iraq and Afghanistan. Traumatic Brain Injury often
manifests in the same way as stroke, with orthotic intervention needed
to address drop foot and other challenges balancing, standing and
walking. The Defense and Veterans Brain Injury Center has reported that
by the start of calendar year 2018, more than 379,500 service members
had suffered a TBI.
Although the death rate from conflicts in Iraq and Afghanistan is
much lower than in previous wars, the amputation rate doubled. The
Department of Defense and the Department of Veterans' Affairs have
reported that in past wars, 3% of service members injured required
amputations; of those wounded in Iraq, 6% have required amputations.
The DoD Surgeon General reported to CRS more than 1,600 service-related
amputations from 2001-2016. More than 80% of amputees lost one or both
legs. Concussion blasts, multiple amputations, and other conditions of
war have resulted in injuries that are medically more complex than in
previous conflicts. The majority of these amputees are young men and
women who should be able to live long, active, independent lives -
sometimes even return to active duty - if they receive timely, high
quality, and consistent prosthetic care.
Senior Veterans Need Orthotic and Prosthetic Care
Most Americans are unaware that the majority of Veterans with
amputations undergo the procedure as a result of diabetes or
cardiovascular disease. According to VA statistics, one out of every
four Veterans receiving care has diabetes; 52% have hypertension; 36%
are obese. These conditions are associated with higher risk for stroke,
neuropathy, and amputation.
These underlying health conditions are the reason that the number
of Veterans undergoing amputation is increasing dramatically, and is
expected to increase at an even more rapid pace in the future. VHA
Amputation System of Care figures show that, in the year 2000, 25,000
Veterans with amputations were served by the VA. By 2016, that number
had more than tripled to 89,921. Between 2008-2013, an average of 7,669
new amputations were performed for Veterans every year; in 2016, 11,879
amputation surgeries were performed. 78% of the Veterans undergoing
amputation last year were diabetics. 42% had a service-connected
amputation condition.
Demand for High Quality Care is Growing While Provider Population
Shrinks
From the battlefield to the homeland, medical conditions requiring
prosthetic and orthotic care have become more complex and more
challenging to treat. New prosthetic and orthotic technology is more
sophisticated, and offers potential for greater functional restoration.
To ensure professional, high quality care that responds to these
shifts, earlier this decade the entry-level qualifications for
prosthetists and orthotists were elevated from a bachelor's degree to a
master's degree.
Veterans need and deserve clinicians who can successfully respond
to their battlefield injuries and service-related health conditions
with appropriate, advanced technologies. As the population of amputees
grows, many experienced professionals who were inspired to enter the
field to care for Vietnam Veterans are retiring. Currently, only 13
American universities offer master's degrees in prosthetics and
orthotics. The largest progra admits fewer than 50 students each year.
The majority of programs enroll fewer than 20 students. Despite
receiving multiple qualified applicants for every seat, fewer than 250
students are able to enroll in all 13 programs combined each year.
Providing high quality care to our Wounded Warriors and Veterans with
limb loss and impairment is going to require more master's degree
graduates from American universities to be the next generation of
practitioners.
The National Commission on Orthotics and Prosthetics Education
(NCOPE) joined with AOPA to commission an independent study of the O&P
field, which was completed in May of 2015. The study found that in
2014, there were 6,675 licensed and/or certified orthotists and
prosthetists in the United States. It concluded that, by 2025,
``overall supply of credentialed O&P providers would need to increase
by about 60 percent to meet the growing demand.'' Subsequent analysis
conducted by NCOPE and AOPA suggests that the current number of
providers is closer to 5,500, an even more significant shortage than
than previously predicted.
Current accredited schools will barely graduate enough entry-level
students with master's degrees to replace the clinicians who will be
retiring in coming years. Class sizes simply aren't adequate to meet
the growing demand for O&P care created by an aging population and
rising incidence of chronic disease.
Positions as licensed, certified prosthetists and orthotists are
good jobs. Nationally, the average wage exceeds $65,000. These jobs pay
good wages, support a family, and can't be outsourced overseas. Most
importantly, they help improve the health and quality of life for our
Veterans. Veterans need care. The providers who care for them need high
quality employees. People want fulfilling careers, and feel great about
caring for the men and women who have so nobly served our country.
Schools are getting more applicants for O&P programs than they can
accept. Where is the imbalance?
The Wounded Warrior Workforce Enhancement Act
O&P master's programs are costly and challenging to expand. The
need for lab space and sophisticated equipment, and the scarcity of
qualified faculty with PhDs in related fields, contribute to the
barriers to expanding existing accredited programs. There are currently
no federal resources available to schools to help create or expand
advanced education programs in O&P. Funding is available for
scholarships to help students attend O&P programs, but do not assist in
expanding the number of students those programs can accept.
One way to address this problem is by passing The Wounded Warrior
Workforce Enhancement Act, introduced in the House by Representative
Cartwright with bipartisan support. This bill is a limited, cost-
effective approach to assisting universities in creating or expanding
accredited master's degree programs in orthotics and prosthetics. It
authorizes $5 million per year for three years to provide one-time
competitive grants of $1-1.5 million to qualified universities to
create or expand accredited advanced education programs in prosthetics
and orthotics. Priority is given to programs that have a partnership
with Veterans' or Department of Defense facilities, including
opportunities for clinical training, to ensure that students become
familiar with and can respond to the unique needs of service members
and Veterans. The bill was endorsed by Vietnam Veterans of America and
VetsFirst, which recognize the need for additional highly qualified
practitioners to care for wounded warriors.
In May of 2013, the Senate Committee on Veterans Affairs held a
hearing to consider the Wounded Warrior Workforce Enhancement Act and
other Veterans' health legislation. The VA testified that the grants to
schools were not necessary because it did not anticipate any difficulty
filling its seven open internal positions in prosthetics and orthotics.
The VA testified that its O&P fellowship program, which accepted
nineteen students that year, was a sufficient pipeline to meet its need
for internal staff. The VA offered similar testimony at a House
Veterans Affairs Health Subcommittee hearing in November 2015.
The Senate rejected the VA's argument. Acknowledging that most
prosthetic and orthotic care to Veterans is provided by community-based
facilities, the Committee concluded that nineteen students could not
meet the system-wide need. Committee members also agreed that Veterans
and the VA would benefit from a larger pool of clinicians with master's
degrees, whether those graduates were hired internally at the VA, or by
community-based providers. The Committee included provisions of the
Wounded Warrior Workforce Enhancement Act in S. 1950, which passed
Senate VA Committee unanimously in 2013. Due to factors unrelated to
O&P, the omnibus bill did not advance. Related provisions were included
in the Senate's omnibus package Veterans' legislation in 2016, but were
not included in the final conferenced bill.
AOPA looks forward to working with you to expand the number of
highly qualified prosthetists and orthotists who can meet the needs of
Veterans with limb loss and limb impairment, and to reducing the
barriers to timely, appropriate lower extremity care. No Veteran should
suffer from decreased mobility or independence because of lack of
access to high quality care, regardless of where it is provided.
A Proud History of Caring for Veterans in the Community Is Under Threat
AOPA commends the VA for its historical leadership in ensuring that
Veterans who have undergone amputations have access to appropriate,
advanced prosthetic technology, often before the same technology is
made available to patients in the private sector. For example, when the
first microprocessor-controlled knee came to market, it was initially
considered beneficial for the fittest, most active amputees. Fred
Downs, then National Director of the Prosthetic and Sensory Aids
Service, was himself a Vietnam Veteran who lost an arm in combat. He
had the idea that the greater stability offered by microprocessor
control might be even more beneficial to older, less active Veterans
with limb loss who were less steady on their feet. After testing the
computer-controlled knees with older Veterans undertaking activities
such as walking in the community and riding Metro escalators, the VA
became the first payor to approve microprocessor-controlled knees for
older and less active patients. Today, following the VA, Medicare and
private insurance companies widely accept that microprocessor-
controlled knees improve safety and increase activity levels for
patients with limb loss across a wide spectrum of activity levels.
O&P care is unusual in providing care to Veterans largely through
contracts with private sector providers - often family-owned, small
businesses. There are multiple advantages to the VA, and to Veterans,
from this long-time public-private partnership in O&P. With a private
sector network of O&P clinics supplementing care available from VA
employees, wait times are reduced and Veterans receive the care they
need more quickly than if they were relying solely on overburdened VA
facilities and federal employees. Community-based providers are often
closer to Veterans' homes or workplaces. Frequently, they offer
Veterans more convenient care, with less travel time and expense, less
time away from work, and less interruption to their daily lives.
It is in part because of this strong history of providing high
quality care in the community to Veterans who need it that AOPA is
deeply concerned by the October 16, 2017 Federal Register Notice and
proposed rule regarding ``Prosthetic and Rehabilitative Items and
Services.'' Under the proposed rule, the Veterans' Administration, not
the Veteran, would decide if a Veteran can receive care from a local
provider or if that Veteran must drive - sometimes for hours, over
hundreds of miles - to receive care in a VA facility. In fact, the
proposed policy states that, if the VA has the materials in-house, care
shall be provided in the VA. The policy, which is described in the
Federal Register as a ``clarification,'' in fact upends decades-long
precedent allowing Veterans to choose to receive prosthetic and
orthotic care in the community. AOPA is grateful to Representatives
Walberg and Rutherford, who recently offered an amendment prohibiting
use of appropriated funds to finalize the proposed policy. AOPA joins
with Veterans' Service Organizations that have called for the VA to
withdraw this proposal immediately, and urges the VA instead to
affirmatively rebuild the public-private partnership that has provided
such high quality care.
AOPA is also deeply concerned about the impediments the coding
policies of the Centers for Medicare and Medicaid services are posing
with respect to the development of new, more advanced technologies
needed by prosthetic and orthotics patients, and Veteran access to
these advanced technologies. The VA recently announced that it would
reverse its longstanding practice of making payments for new prosthetic
technologies under a ``Not Otherwise Classified'' code. This decision,
and other related policies, appear to be limiting Veterans' access to
newer, advanced and more effective prosthetic and orthotic
technologies. The VA has never provided a comprehensive explanation for
its policy changes. We are grateful to former Subcommittee Chairman
Wenstrup for his work on this issue, including his work on a joint
hearing or round table with the House Ways and Means Committee.
Chairman Dunn, Ranking Member Brownley, and members of the
Committee, we know you share our belief that Veterans who have suffered
limb loss or limb impairment as a result of their military service, or
as a result of service-connected illness, deserve the best possible
care that a grateful country can provide. We look forward to working
with you to ensure that all Veterans continue to receive that care.
MILITARY OFFICERS ASSOCIATION OF AMERICA
CHAIRMAN DUNN, RANKING MEMBER BROWNLEY, and Members of the
Subcommittee on Health, the Military Officers Association of America
(MOAA) is pleased to submit its views on pending legislation under
consideration.
MOAA does not receive any grants or contracts from the federal
government.
EXECUTIVE SUMMARY
On behalf of the 350,000 members of the Military Officers
Association of America, the largest military service organization
representing the seven uniformed services, including active duty and
Guard and Reserve members, retirees, veterans, and survivors and their
families, thank you for your commitment and enduring support of our
nation's servicemembers, veterans and their families.
MOAA offers our position on the following bills.
H.R. 2787, Veterans-Specific Education for Tomorrow's
Medical Doctors Act
H.R. 3696, Wounded Warrior Workforce Enhancement Act
H.R. 5693, Long-Term Care Veterans Choice Act
H.R. 5864, VA Hospitals Establishing Leadership
Performance Act
DRAFT Bill, Veterans Serving Veterans Act
MOAA takes no position on: H.R. 5521, VA Hiring Enhancement Act;
H.R. 5974, VA COST SAVINGS Enhancement Act; and, the draft bill To
Improve the Productivity and Management of VA Health Care Facilities.
These bills are outside of our scope of expertise.
PENDING LEGISLATION
H.R. 2787, Veterans-Specific Education for Tomorrow's Medical
Doctors Act (VET MD Act). MOAA supports this legislation. However, we
urge Congress to commit the necessary resources and funding to execute
the program.
The VET MD Act would allow the VA to establish a pilot program
instituting a clinical observation program for pre-med students
preparing to attend medical school.
The association is grateful to Representatives Kaptur, Jones, and
Ryan for introducing the bill and for the Subcommittee's consideration
of this important piece of legislation. Like lawmakers, MOAA is eager
for the VA to try new and innovative approaches growing the agency's
medical workforce and eliminating the current 30,000-plus vacancies
across its health care system. This legislation would introduce
prospective medical students to the kinds of health care conditions
common to the veteran population and help the VA encourage students to
choose a career in medicine, particularly in occupational fields with
high staffing shortages, such as women's health care and psychiatric
care and/or consider a career in veterans' health care at the agency.
While the legislation only requires the VA to establish procedures
to track students participating in the clinical observation program to
determine if the student was accepted into medical school, MOAA
recommends this Subcommittee consider adding a provision requiring the
VA to continue tracking these students through medical school and
residency programs in an effort to secure medical professionals for VA
employment and to ascertain the effectiveness of the clinical
observation program to individuals deciding on a career in medicine who
are interested in treating the veteran population.
H.R. 3696, Wounded Warrior Workforce Enhancement Act. MOAA supports
this legislation and requests Congress provide the associated funding
needed to support the legislative requirements of this bill.
The Wounded Warrior Workforce Enhancement Act would require the VA
to award grants to establish or expand upon master's degree programs
with academic medical institutions in the fields of orthotics and
prosthetics. Further, the VA shall award a grant to an eligible
institution to establish a Center of Excellence in Orthotic and
Prosthetic Education to conduct evidence-based research and to improve
health outcomes for veterans, servicemembers, and civilians.
The legislation also allows grants to eligible institutions
planning to expand their existing master's degree program in these two
fields by admitting more students or adding faculty to the program,
expanding existing facilities, or by increasing cooperative
partnerships with the VA and DoD.
Military service today has unique occupational demands and hazards.
Servicemembers are required to carry heavy rucksacks and body armor in
physically demanding training and harsh combat environments. Increased
exposure to improvised explosive devices has resulted higher rates of
injury among Post-9/11 troops, including amputations, and lower
extremity conditions. Veterans are also presenting in increasing
numbers for foot and ankle ailments, conditions complicated by
diabetes, and neuropathy often associated with Agent Orange exposure,
orthopedic, or vascular problems.
MOAA believes H.R. 3696 would provide the VA an additional tool it
needs to address staffing shortages in the area of orthotics and
prosthetics and help the agency attract high quality providers to meet
current and future needs of veterans needing these important services
within VA's integrated network of care.
H.R. 5693, Long-Term Care Veterans Choice Act. MOAA supports this
bill as long as the requisite associated funding is provided for
implementation.
The Long-Term Care Veterans Choice Act would authorize the VA to
place veterans who are unable to live independently in private medical
foster homes at the expense of the government.
Many veterans live with complex chronic diseases or disabling
traumatic injuries and over time these individuals may be unable to
live independently or their health care needs become such their family
caregiver may no longer be able to manage their care. In recent years,
the VA has established a medical foster home program to prevent this
population of veterans being institutionalized or delay entering
nursing home care, instead allowing for them to be placed in a home in
their community as a more acceptable alternative of care for the
veteran. Veterans are placed in a home with other veterans and have a
live-in qualified caregiver to support their medical needs 24/7.
While VA is required to provide institutional care, such as nursing
home services to veterans who qualify for health care and have a
service-connected disability rating of 70 percent or higher or are
considered unemployable and have a disability rating of 60 percent or
higher, the agency cannot directly pay for care through the medical
foster home program. Veterans participating in the foster home program
typically pay for these services from monthly VA disability
compensation and Social Security payments and personal saving accounts.
VA recognizes the positive health outcomes and costs savings
associated with veterans receiving care and services through the foster
home program. This legislation would provide VA the mechanism to pay
for the care directly so veterans and their families would not have to
forfeit earned benefits to pay for care they would otherwise be
entitled to if they were receiving institutionalized care.
H.R. 5864, VA Hospitals Establishing Leadership Performance Act.
MOAA supports this legislation.
H.R. 5864 would require the VA to establish qualifications and
standardized performance metrics for each human resources position
within the veterans' health care system and submit a report to Congress
on these qualifications and standards. The Comptroller General is
required to follow up with a report on how the VA implemented the
requirement to include an assessment of the quality of the
qualifications and performance metrics adopted by the agency.
MOAA is pleased to see the legislation put forth to improve and
strengthen VA's human resources system. Effective transformation will
require leaders at all levels of the organization to be responsible and
accountable for improving organizational health and staff engagement.
Such transformation must include reforming and modernizing the VA's
leadership and human capital management systems across the enterprise.
While MOAA would like to see more comprehensive human resources
strategy for system change along with the technology, resources, and
funding to support the overhaul, H.R. 5864 is a foundational element to
begin the massive overhaul needed to recruit, retain, and sustain a
viable workforce. If we are to address the ongoing medical staffing
shortages within the VA, then securing and sustaining high quality
human resource professionals is essential.
DRAFT Bill, Veterans Serving Veterans Act. MOAA supports this
legislation.
The Veterans Serving Veterans Act would permit the department to
establish a database to capture specialties and skills of medical
members of the Armed Forces to facilitate recruitment and address the
occupational workforce needs of the VA.
The legislation would also require the department to establish and
implement a training and certification program for veterans to work as
medical technicians in VA.
The database, to be called the ``Department of Defense and Veterans
Affairs Recruitment Database,'' is intended to be a single, searchable
platform by which the two departments can exchange information on
military occupational specialty or skills of consenting members of the
Armed Forces who might be qualified after being discharged and released
from active duty to fill medical vacancies in the VA. VA would be
authorized to use direct hiring and appointment authorities and may
authorize a relocation bonus to expedite hiring.
Just as H.R. 5864 listed above offers an opportunity to address
critical workforce shortfalls, the Veterans Serving Veterans Act is
equally important in identifying and securing critical medical
professionals who may be qualified and interested in serving in the VA.
MOAA has advocated for years for more collaboration and communications
between DoD and VA as one of many ways to address VA's critical
professional and technical medical staffing shortages. MOAA is pleased
to support this important legislation and is confident DoD and VA can
implement the provisions in this bill with minimal cost to either
department as the database should be considered a standard tool and
requirement for use by human resources professionals.
MOAA thanks the Subcommittee for considering these important pieces
of legislation and we look forward to working with members of Congress
in making the necessary changes listed above and to move the bills
quickly through the Congress for final passage.
PARALYZED VETERANS OF AMERICA
Chairman Dunn, Ranking Member Brownley, and members of the
Subcommittee, Paralyzed Veterans of America (PVA) would like to thank
you for the opportunity to submit our views on the broad array of
pending legislation impacting the Department of Veterans Affairs (VA)
that is before the Subcommittee. No group of veterans better
understands the full scope of care provided by the VA than PVA's
members-veterans who have incurred a spinal cord injury or disease.
Most PVA members depend on VA for 100 percent of their care and are the
most vulnerable when access and quality of care is threatened. Several
of these bills will help to ensure veterans receive timely, quality
care and services.
H.R. 2787, the ``Veterans-Specific Education for Tomorrow's Medical
Doctors Act''
PVA supports H.R. 2787, the ``Veterans-Specific Education for
Tomorrow's Medical Doctors Act.'' This bill would establish a pilot
program in the VA for pre-med students to experience clinical
observation before attending medical school. The pilot would be carried
out for a three-year period at no more than five medical centers. The
goals of this clinical observation pilot would be to increase awareness
and knowledge of veterans' health care for future medical professionals
and increase provider diversity. While VA does already allow for
clinical observation, this pilot would assist in enhancing the
awareness of veteran-specific needs among future medical professionals.
Each session would allow for no fewer than 20 students and 60
observational hours with three sessions per calendar year. In selecting
which medical centers and specialties are to participate, the Secretary
may select those with the largest staffing shortages. PVA recommends VA
provide the participating students with information regarding
employment at VA, including educational opportunities and loan
repayment programs.
H.R. 3696, the ``Wounded Warrior Workforce Enhancement Act''
PVA supports the goal of this legislation to the extent that it
attempts to rejuvenate a declining orthotics and prosthetics workforce.
We have a concern, however, as to whether the veteran community will
truly capitalize on the return on this investment if the legislation
does not require some level of service commitment from student
beneficiaries.
Quality orthotic and prosthetic care is of the utmost importance to
PVA members. No group of veterans understands the importance of
prosthetics and orthotics more than veterans with spinal cord injury or
disease. The Independent Budget Veteran Service Organizations (IBVSOs)
maintain that the VA must ensure that prosthetics departments are
staffed by certified professional personnel or contracted staff that
can maintain and repair the latest technological prosthetic devices. A
key component to this is continued support for the VA National
Prosthetics Technical Career Program which aims to address the
projected personnel shortages.
In June of 2015, the National Commission on Orthotic and Prosthetic
Education (NCOPE) released its analysis projecting orthotics and
prosthetics workforce supply and patient demand over the next ten
years. The analysis showed that the overall number of credentialed O&P
providers will need to increase approximately 60 percent by 2025 to
meet the growing demand. This is in part due to the fact that attrition
rates from the profession will surpass the graduation rates of those
entering the field, ultimately resulting in a decreasing supply of
orthotics and prosthetics providers. Failure to address both the
decreasing supply of providers and the increasing demand for their
services will very likely cause the workforce to shift toward non-
credentialed providers. Our veterans deserve to be cared for by
competent and highly trained individuals.
This legislation is an important step toward ensuring that our
veterans continue to be treated by credentialed providers. It promotes
the expansion of a qualified teaching and faculty pool which will
provide the foundation to accommodate and train a growing number of
students seeking to become providers. In addition to the expected
dissemination of best practices and knowledge from the proposed Center
of Excellence, the legislation also provides eligible institutions
built-in flexibility to tailor and use the funds for educational areas
where they can achieve the goal of expanding the orthotics and
prosthetics workforce most effectively. PVA also supports the proposed
veterans' preference in the admissions process. As the IBVSOs have
stated before, employing veterans in this arena will ensure a balance
between the perspective of the clinical professionals and the personal
needs of the disabled veterans.
PVA's concern, though, is that the bill misses an opportunity to
capture a more predictable and tangible return on investment. Requiring
scholarship recipients to serve a commitment with the VA is a way to
strengthen the precision with which these funds are allocated without
reducing the previously mentioned institutional flexibility. The goal
of this legislation is, after all, to expand the orthotics and
prosthetics workforce in order to better serve veterans. While the
proposed approach of expanding the overall pool of qualified service
providers within the community writ large might have a trickle effect
of ensuring that the VA continues to offer certified providers, we
believe this suggested change would have a stronger and more immediate
impact.
H.R. 5521, the ``VA Hiring Enhancement Act''
PVA supports H.R. 5521, the ``VA Hiring Enhancement Act.'' The bill
would amend title 38 to provide for the non-applicability of non-VA
covenants not to compete to the appointment of certain Veterans Health
Administration personnel. It would also permit VHA to make contingent
appointments and require VA physicians to complete residency training.
This bill intends to fill vacancies and make VA more competitive by
authorizing VHA to begin the recruitment and hiring process up to two
years prior to the completion of required training. This would allow
for physicians to quickly begin work at VA medical centers upon the
completion of their education. This could help to stem the flow of the
ever recurring stories of young clinicians who wished to serve veterans
but were unable to endure the months of an uncertain onboarding
process. Veterans deserve the best this country can offer. Congress
should explore every means to ensure VA does not lose out on young
professionals due to inefficient hiring practices.
H.R. 5693, the ``Long-Term Care Veterans Choice Act''
PVA supports H.R. 5693, the ``Long-Term Care Veterans Choice Act.''
This bill proposes to amend title 38 to authorize the VA to enter into
contracts or agreements for the transfer of veterans to non-VA adult
foster homes for certain veterans who are unable to live independently.
PVA believes that VA's primary obligation involving long-term support
services is to provide veterans with quality medical care in a healthy
and safe environment.
As it relates to veterans with a catastrophic injury or disability,
it is PVA's position that adult foster homes are only appropriate for
disabled veterans who do not require regular monitoring by licensed
providers, but rather are able to maintain a high level of independence
despite needing assistance due to having a catastrophic injury or
disability. When these veterans are transferred to adult foster homes,
care coordination with VA specialized systems of care is vital to the
veterans' overall health and well-being. The drafted text of this bill
requires the veteran to receive VA home health services as a condition
to be transferred. As such, PVA believes that if a veteran with a
spinal cord injury or disease (SCI/D) is eligible and willing to be
transferred to an adult foster home, the VA must have an established
system in place that requires the VA home-based primary care team to
coordinate care with the VA SCI/D Center and the SCI/D primary care
team that is in closest proximity to the adult foster home. When caring
for a veteran with a catastrophic injury or disability this specialized
expertise is extremely important to prevent and treat associated
illnesses that can quickly manifest and jeopardize the health of the
veteran. When catastrophically injured or disabled veterans who receive
services from one of the VA's specialized systems of care are placed in
a non-VA adult foster home they must be regularly evaluated by
specialized providers who are trained to meet the needs of their
specific conditions.
H.R. 5864, the ``VA Hospitals Establishing Leadership Performance Act''
PVA supports H.R. 5864, the ``VA Hospitals Establishing Leadership
Performance Act'' that would direct the Secretary to establish
qualifications for the human resources positions within VHA. It would
also require VA to standardize performance metrics and report the
findings to Congress. There currently are no such requirements.
H.R. 5974, the ``Department of Veterans Affairs Creation of On-Site
Treatment Systems Affording Veterans Improvements and Numerous
General Safety Enhancements Act''
PVA supports H.R. 5974, the ``Department of Veterans Affairs
Creation of On-Site Treatment Systems Affording Veterans Improvements
and Numerous General Safety Enhancements Act.'' This legislation would
direct the Secretary to use on-site regulated medical waste treatment
systems at certain VA facilities.
Currently, most VA facilities dispose of medical and biohazardous
waste by contracting for its removal by truck. This method is
expensive, and poses inherent risk by loading waste, such as blood,
microbiological cultures, body parts, dressings, etc., onto vehicles
that must travel to disposal sites. The opportunity for accidents,
spillage, and exposure to the public are ever present. This legislation
would allow, where it results in savings, for VA to discard its own
waste using on-site regulated medical waste treatment systems.
H.R. 5938, the ``Veterans Serving Veterans Act of 2018"
PVA supports the intent of this legislation. However, we have some
concerns regarding the level of interagency cooperation it would take
to enact this legislation. We are eager to learn the position of VA and
the Department of Defense (DOD) regarding this bill. Additionally, we
have some concerns regarding privacy.
The draft bill would establish a vacancy and recruitment database
to facilitate the recruitment of soon to separate members of the Armed
Forces in order to fill vacant positions at VA. To do so, it requires
DOD to provide the names and contact information of every member of the
Armed Forces whose military occupational specialty or skill corresponds
to an employment vacancy at the VA. We are unconvinced the current
employment databases are so insufficient to navigate that it justifies
this degree of interagency upkeep as well as the upfront provision of
the names, contact information, and skillsets of individuals soon to
leave the military. Most concerning, this database of DOD information,
to be maintained by VA, would automatically submit service members'
information and require one to opt-out, rather than opt-in, in writing.
While PVA commends the intent of this legislation, to fill vacancies
and provide suitable employment to newly separated service members, we
recommend privacy and efficiency concerns be addressed.
Draft legislation, ``to improve productivity of the management of
Department of Veterans Affairs health care, and for other
purposes''
PVA supports the intent of this draft legislation. As written, the
draft would require VA to track relative value units (RVU) for all VA
providers. It would also require all providers to attend training on
clinical procedure coding. In addition, it would direct the Secretary
to establish for each facility standardized performance standards based
on RVUs that are applicable to each specialty, as well as remediation
plans for low productivity and clinical inefficiencies.
RVUs, a private sector standard used to determine productivity
against expenses, has been a widely used tool by the Centers for
Medicare and Medicaid Services for decades. The primary purpose of
which is not to enhance patient outcomes but to determine provider
payments. While RVUs could be useful, they are not perfectly applicable
for a holistic health system like VA.
PVA strongly supports the use of any tool that betters the care
veterans receive. If legislation proposed a tool that would both
increase quality and save the taxpayer, we would support it. However,
we are not convinced the RVU measure will motivate providers at
facilities appropriately. A private sector model is not applicable to
veteran centric, complex care provided at VA. As the private sector
rarely discloses their own performance under such measurement, we are
hesitant to support a flawed comparison between the two systems that
benefits neither.
As is often noted, VA providers spend far more time with patients
compared with the private sector, to the increased satisfaction of the
veteran. And since providers are not compensated by quantity of
patients seen, the incentive to spend quality time with a patient is
encouraged. We are eager to learn VA's position on this bill.
PVA would once again like to thank the Subcommittee for the
opportunity to submit our views on the programs affecting veterans. We
look forward to working with you to ensure our catastrophically
disabled veterans and their families receive the medical services and
supports they need.