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VA ACCOUNTABILITY: ASSESSING ACTIONS TAKEN 

IN RESPONSE TO SUBCOMMITTEE OVERSIGHT 

HEARING 

BEFORE THE

SUBCOMMITTEE ON HEALTH 

OF THE

COMMITTEE ON VETERANS’ AFFAIRS 

U.S. HOUSE OF REPRESENTATIVES 

ONE HUNDRED THIRTEENTH CONGRESS 

SECOND SESSION 

WEDNESDAY, FEBRUARY 26, 2014 

Serial No. 113–54 

Printed for the use of the Committee on Veterans’ Affairs 

( 

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


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COMMITTEE ON VETERANS’ AFFAIRS 

JEFF MILLER, Florida, Chairman 

DOUG LAMBORN, Colorado 

GUS M. BILIRAKIS, Florida, Vice-Chairman 

DAVID P. ROE, Tennessee 

JEFF DENHAM, California 

BILL FLORES, Texas 

JON RUNYAN, New Jersey 

DAN BENISHEK, Michigan 

TIM HUELSKAMP, Kansas 

MIKE COFFMAN, Colorado 

BRAD R. WENSTRUP, Ohio 

PAUL COOK, California 

JACKIE WALORSKI, Indiana 

DAVID JOLLY, Florida 

MICHAEL H. MICHAUD, Maine, Ranking 

Minority Member 

CORRINE BROWN, Florida 

MARK TAKANO, California 

JULIA BROWNLEY, California 

DINA TITUS, Nevada 

ANN KIRKPATRICK, Arizona 

RAUL RUIZ, California 

GLORIA NEGRETE MCLEOD, California 

ANN M. KUSTER, New Hampshire 

BETO O’ROURKE, Texas 

TIMOTHY J. WALZ, Minnesota 

JON TOWERS, Staff Director 

NANCY DOLAN, Democratic Staff Director 

SUBCOMMITTEE ON HEALTH 

DAN BENISHEK, Michigan, Chairman 

DAVID P. ROE, Tennessee 

JEFF DENHAM, California 

TIM HUELSKAMP, Kansas 

JACKIE WALORSKI, Indiana 

BRAD R. WENSTRUP, Ohio 

JULIA BROWNLEY, California, Ranking 

Minority Member 

CORRINE BROWN, Florida 

RAUL RUIZ, California 

GLORIA NEGRETE MCLEOD, California 

ANN M. KUSTER, New Hampshire 

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. 


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C O N T E N T S 

Page 

Wednesday, February 26, 2014 

VA Accountability: Assessing Actions Taken In Response To Subcommittee 

Oversight .............................................................................................................. 1 

OPENING STATEMENTS 

Hon. Dan Benishek, Chairman ............................................................................... 1 

Prepared Statement ......................................................................................... 31 

Hon. Julia Brownley, Ranking Member ................................................................ 3 

Prepared Statement ......................................................................................... 32 

WITNESS 

Hon. Robert Petzel, M.D., Under Secretary for Health, Veterans Health Administration, U.S. Department of Veterans’ Affairs .......................................... 5 

Prepared Statement ......................................................................................... 33 

Accompanied by: 

Robert Jesse, M.D., Principal Deputy Under Secretary for Health 

VHA, U.S. Department of Veterans Affairs 

Madhulika Agarwal, M.D., M.P.H., Deputy Under Secretary for 

Health for Policy and Services, Veterans Health Administration, 

U.S. Department of Veterans Affairs 

Rajiv Jain M.D., Assistant Deputy Under Secretary for Patient Care 

Services, VHA, U.S. Department of Veterans Affairs 

And 

Phillip Matkovsky, Assistant Deputy Under Secretary for Health for 

Administrative Operations, VHA, U.S. Department of Veterans 

Affairs 

MATERIAL SUBMITTED FOR THE RECORD 

Letter and Questions From: Hon. Dan Ben to Hon. Robert A. Petzel ................ 39 

Questions From: Hon. Dan Benishek and Responses From: VA ......................... 42 

Letter From: Hon. Robert A. Petzel to Hon. Dan Benishek ................................. 73 

Deliverables From: VA ............................................................................................ 73 


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VA ACCOUNTABILITY: ASSESSING ACTIONS 

TAKEN IN RESPONSE TO SUBCOMMITTEE 

OVERSIGHT 

Wednesday, February 26, 2014 

U.S. HOUSE OF REPRESENTATIVES, 

COMMITTEE ON VETERANS’ AFFAIRS, 

SUBCOMMITTEE ON HEALTH, 

Washington, D.C. 

The subcommittee met, pursuant to notice, at 10:04 a.m., in 

Room 334, Cannon House Office Building, Hon. Dan Benishek 

[chairman of the subcommittee] presiding. 

Present: Representatives Benishek, Huelskamp, Wenstrup, 

Brownley, Ruiz, Negrete-McLeod, and Kuster. 

OPENING STATEMENT OF DAN BENISHEK, CHAIRMAN 

Dr. BENISHEK. Good morning. The subcommittee will come to 

order. 

Thank you for joining us today for the oversight hearing VA Accountability: Actions Taken in Response to Subcommittee Oversight. 

Almost one year ago today during my first hearing as chairman 

of the Subcommittee on Health, we met to discuss the persistent 

lack of productivity and staffing standards for specialty care services at Department of Veterans Affairs’ medical facilities. 

We learned that VA had yet to implement these standards despite more than 30 years of reports and recommendations directing 

the department to do so. 

I was so alarmed by VA’s decades long lack of action that I 

quickly introduced H.R. 2072, the Demanding Accountability for 

Veterans Act. H.R. 2072 would require VA to ensure that inspector 

general recommendations concerning a public health or patient 

safety issue were addressed, identify those within VA medical facilities who are responsible for implementing needed changes, and 

prohibit the VA from awarding a bonus or performance award to 

any employee who does not fully address a recommendation under 

his or her purview. 

The goal of this legislation is to create a culture of accountability 

within VA, a culture where problems are identified and immediately corrected and leaders are held responsible for their actions. 

Were H.R. 2072 in place 30 years ago, VA would have been required long before now to implement productivity and staffing 

standards for all specialty care services and who knows how the 

health and well-being of a veteran seeking care through VA would 

have improved as a result. 


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I wish I could say that the first hearing was the only time that 

we have seen evidence of a lack of timely action taken by VA in 

response to serious problems. Unfortunately, that is not true. 

Since the conclusion of that hearing, we have held other hearings 

and roundtables on topics ranging from the care provided to veterans with chronic pain and who have experienced military sexual 

trauma to concerns regarding department-wide procurement reform 

and third-party collections. 

At each of these oversight forums, we have heard example after 

example of VA failing to act swiftly to address important issues or 

respond to the subcommittee’s requests for information in a timely 

manner. 

I am a surgeon. When a serious problem is identified, my instinct 

is to act without delay, to cut out what needs cutting out, and to 

fix what needs fixing. 

While I understand that large-scale changes often happen slowly, 

especially where large government bureaucracies like VA are concerned, I think we can all agree that our veterans deserve more 

than what we have seen in the last year. 

I am hopeful that H.R. 2072 will be heard on the House floor in 

the coming weeks. However, I am not content to wait for what can 

often be a lengthy legislative process to ensure that VA is on track 

to address the many issues the subcommittee has identified 

through last year’s oversight efforts. 

During today’s hearing, we will assess the progress, if any, that 

VA has made in response to the subcommittee’s hearings and 

roundtables, determine whether appropriate steps have been taken 

to ensure accountability when and where deficiencies in care have 

been highlighted, and identify what further actions may be necessary to improve the care and services provided to our veterans. 

Though the topics we address today are wide ranging, they are 

undoubtedly interconnected. If we do not ensure the department is 

on track to implement appropriate productivity and staffing standards, then we cannot be sure that we have the right staff in place 

to care for veterans experiencing chronic pain. 

Similarly, if we do not ensure that the VA is taking necessary 

actions to improve the collection where appropriate of third-party 

revenue, then we cannot be sure that we are collecting every available dollar that could be used to improve the care and services provided to veteran survivors of military sexual trauma. 

Last week, I had the privilege of conducting an oversight visit to 

the West LA VA Medical Center. During my conversations with the 

clinicians and support staff there, each of the issues we will discuss 

today were brought up by the providers when I asked them what 

needed to be improved in order to make it easier for them to care 

for our veterans. 

I cannot state enough how critical it is for VA to take responsibility for gaps in care and, more importantly, to take immediate 

and definitive steps to address them. 

Unfortunately, I have seen little concrete evidence in the past 

year that the department is doing either. Concurring with IG and 

GAO reports is simply not enough. Sending out guidelines without 

accountability is not enough. I sincerely hope that today’s conversation will change my mind. 


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[THE PREPARED STATEMENT HON. DAN BENISHEK APPEARS IN THE

APPENDIX] 

With that, I will recognize Ranking Member Brownley for any 

opening statement she may have. 

OPENING STATEMENT OF JULIA BROWNLEY, RANKING 

MEMBER 

Ms. BROWNLEY. Thank you, Mr. Chairman, and good morning. 

Today’s hearing is intended to follow-up on various oversight 

hearings and roundtables held during the first session of the 113th 

Congress and to assess the progress that the department has made 

in addressing these critical issues. 

The subcommittee will also determine whether appropriate steps 

have been taken by the VA to ensure accountability and identify 

what further actions may be necessary in response to subcommittee 

oversight. 

Last session, this subcommittee held oversight hearings on physician staffing standards, care and treatment for military sexual 

trauma survivors, and VA’s overuse of prescription painkillers to 

treat veterans with chronic pain. 

In addition to the oversight hearings, two roundtables were held, 

one focusing on procurement reform and access to care and one on 

billing and collecting from third-party health insurance companies 

for nonservice-connected care. 

There were many issues raised during these hearings and 

roundtables, issues such as developing a plan to establish productivity standards for all specialty care services within three years, 

decreasing the amount of time it takes to procure large medical 

equipment through the national acquisition center, assessing the 

department’s programs for veterans who have experienced military 

sexual trauma, and ensuring the effective use of opiate therapy for 

patients with chronic pain. 

Mr. Chairman, these are but a few of the concerns that were 

brought up during testimony and conversations we had with the 

witnesses and participants during these forums. While we have a 

lot of ground to cover today, I am especially interested in hearing 

from the VA on improvements made in the military sexual trauma 

program and in procurement reform. 

At the MST hearing held last session, we heard firsthand the experiences of veterans who have found the system unfriendly and intimidating. 

According to the VA, fiscal year 2013 saw an increase of 9.3 percent in rates of engagement of military sexual trauma related care 

at VHA. Additionally, the VA reports an increase of 14.6 percent 

in military sexual trauma related visits in fiscal year 2013. 

I would like to hear from the VA how they are addressing these 

increases. I am sure we all agree that it is critical that Congress 

do all that we can to make it easier for victims of military sexual 

trauma to access needed benefits and services and receive treatment. Compassion and care are a significant part of healing those 

that have been sexually assaulted. 

Turning now to procurement reform, Mr. Chairman, last session, 

we held a roundtable and during that roundtable discussion, we 


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heard about the long delays, some for up to two years, in the delivery of medical equipment. 

While I understand that VA is streamlining the procurement 

process to decrease the amount of time it takes to procure large 

medical equipment through the national acquisition center, I do not 

feel confident that much progress has been made in that area. 

Stakeholders continue to report increased difficulties accessing 

needed prosthetic equipment through VA and significant delays in 

contract awards at the national acquisition center. I find this very 

frustrating and unnecessary. I hope the VA has good news on this 

front today. 

Mr. Chairman, thank you for holding this hearing today, and I 

want to thank everyone in attendance. There is obvious concern for 

veterans and VA’s ability to meet their healthcare needs. 

Thank you, Mr. Chairman, and I yield back the balance of my 

time. 

[THE PREPARED STATEMENT OF HON. JULIA BROWNLEY APPEARS IN THE

APPENDIX] 

Dr. BENISHEK. Thank you, Ms. Brownley. 

With that, I will introduce our first and only witness panel. Representing the department is the Honorable Under Secretary for 

Health, Dr. Robert Petzel. 

Dr. Petzel is accompanied by Dr. Jesse, the principal deputy 

under secretary for Health; Dr. Agarwal, the deputy under secretary for Health for Policy and Services; Dr. Jain, the assistant 

deputy under secretary for Patient Care Services; and Mr. Philip 

Matkovsky, the assistant deputy under secretary for Health for Administrative Operations. 

Together each of you represent the lead VA witnesses at the 

three oversight hearings and the two roundtable discussions that 

will be the focus of today’s hearing. Thank you all for being here 

today. 

Dr. Petzel, please proceed with your testimony. 


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STATEMENT OF ROBERT PETZEL, UNDER SECRETARY FOR 

HEALTH, VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS, ACCOMPANIED BY ROBERT JESSE, PRINCIPAL DEPUTY UNDER SECRETARY FOR 

HEALTH, VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS; MADHULIKA AGARWAL, 

DEPUTY UNDER SECRETARY FOR HEALTH FOR POLICY AND 

SERVICES, VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS; RAJIV JAIN, ASSISTANT 

DEPUTY UNDER SECRETARY FOR PATIENT CARE SERVICES, 

VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF 

VETERANS AFFAIRS; PHILIP MATKOVSKY, ASSISTANT DEPUTY UNDER SECRETARY FOR HEALTH FOR ADMINISTRATIVE OPERATIONS, VETERANS HEALTH ADMINISTRATION, 

U.S. DEPARTMENT OF VETERANS AFFAIRS 

STATEMENT OF ROBERT PETZEL 

Dr. PETZEL. Good morning, Chairman Benishek and Ranking 

Member Brownley and Members of the committee. Thank you for 

the opportunity to discuss the progress that we have made regarding Veterans Health Administration’s physician staffing, productivity standards, treatment for veterans who experience military 

sexual trauma, pain management, and procurement reform. 

The chairman has already mentioned the people that are accompanying me. 

The Veterans Health Administration is the largest integrated 

healthcare delivery system in the country providing 85 million total 

healthcare appointments and last year, we had 25 million consultation requests. And we deliver this care at 1,700 VA healthcare 

sites. 

I want to address first the issue of accountability. Allegations of 

misconduct by employees are taken seriously by VA. When we 

learn of credible allegations of misconduct, VA addresses them immediately. When incidents occur, we identify, mitigate, and prevent 

additional risks. 

Prompt reviews prevent similar events in the future and hold 

those responsible accountable. If an employee misconduct or failure 

to meet performance is identified, VA does take appropriate action. 

Effectively treating veterans who experience military sexual 

trauma continues to be a top priority for VA. We are committed to 

ensuring that appropriate MST services are available to meet the 

treatment needs of both men and women. 

Since last year’s hearing on military sexual trauma, VA has 

taken a number of steps that have resulted in improvements. VA 

is in the process of administrating and implementing an enhanced 

universal MST screening to include a clinical reminder for referrals. We are providing military sexual trauma telemental health 

for rural veterans and recently we distributed to all affected employees an information bulletin on managing military sexual trauma. 

A number of roundtables were hosted to examine the impact of 

department-wide acquisition reform. Since that roundtable discussion, the department has expanded its use of authorities to acquire 

care from community healthcare providers, successfully launching 


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the patient centered care in the community or PC3. VA has completed its consolidation of billing through the consolidated patient 

account centers. And, additionally, we have welcomed the oversight 

from the Health Subcommittee during our roundtables. We have 

used this oversight process to inform continued improvements in 

our administrative processes which we will illuminate during the 

hearing. 

Last year, we also participated in a hearing regarding VA productivity and staffing. Today I am pleased to report that by the end 

of March 2014, we will have productivity and staffing standards in 

place for 25 different specialties representing 81 percent of our 

total physician workforce. And we are on target to deliver productivity and staffing standards for all VA physicians by the end of fiscal year 2014. 

In October of 2013, VA briefed the OIG on its progress. Based 

on VA’s briefing, the OIG has closed out all of its recommendations 

related to physician staffing. The work continues and will not be 

finished until all physician specialty productivity and staffing 

standards are complete, implemented, and ready access to highquality, efficient specialty care is available to all of our Nation’s 

veterans. 

Lastly, VA is providing comprehensive pain management services 

to improve the health of veterans. As an update to last year’s pain 

management hearing, VA recently developed and implemented an 

opioid safety initiative program to ensure opioid medications are 

used safely, effectively, and judiciously. 

The program is already bringing positive results. The basis for 

this program is to make visible the totality of opioid use at all levels, patient, provider, and facility, in order to identify high-risk situations. 

To support a system-wide approach, VA disseminated guidance 

and tools to help providers to communicate long-term opioid therapy expectations to the staff and to their patients. 

In addition, a multi-module, team-based, stepped-care model has 

been implemented throughout VA. Every VA medical center has a 

pain clinic and a consultation service for pain and opioid monitoring and provider feedback program and the capacity to provide 

interdisciplinary treatment such as physical therapy, behavioral 

therapy, non-opioid medications, and alternative medical care such 

as acupuncture and meditation. 

VA prescribers also have the ability to participate in the state 

prescription drug monitoring program to determine if a patient of 

theirs is receiving controlled substance prescriptions from non-VA 

sources. 

Mr. Chairman, the Department of Veterans Affairs is committed 

to providing the highest quality of care that our veterans have 

earned and that they deserve. 

As mentioned earlier, important progress has been made regarding these programs. We at VA will continue to identify, mitigate, 

and prevent vulnerabilities within our healthcare system wherever 

we find them. VA will continue to ensure accountability and when 

adverse events do occur, we will learn from them, improve our system to prevent these incidents from happening again. 


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This concludes my testimony. I appreciate the subcommittee’s 

continued interest in the health and the welfare of America’s veterans. And at this time, my colleagues and I are prepared to answer your questions. 

[THE PREPARED STATEMENT OF ROBERT PETZEL APPEARS IN THE APPENDIX] 

Dr. BENISHEK. Thank you, Dr. Petzel. I appreciate your response. 

I expect we will have multiple rounds of questions today, and I 

will begin by yielding myself five minutes. 

While the purpose of this hearing is to go over, the issues that 

we raised over the past year in the hearings and roundtables that 

we have done, I just want to ask a few questions about your statement. 

Specifically you said allegations of misconduct by employees are 

taken seriously. When we learn of credible allegations of misconduct, VA addresses them immediately. 

So within the past year, the committee has examined, you know, 

disturbing lapses of leadership including, several incidents around 

VA like at the Pittsburgh VA Medical Center where several veterans succumbed to Legionnaires’ disease. 

There was apparently some improper emergency room care that 

led to three preventable patient deaths at the Memphis VA according to the VA inspector general’s report and recently 19 preventable deaths were reported nationwide including six deaths at the 

Columbia, South Carolina VAMC and three deaths at the Augusta, 

Georgia VAMC due to avoidable delays in care. 

So were these instances I just reported to you, were they considered credible allegations of misconduct? 

Dr. PETZEL. Yes, Mr. Chairman, they were. 

Dr. BENISHEK. So then what specific actions were taken immediately upon your being aware of these? 

Dr. PETZEL. Let’s go back and go through each one of them individually. At Memphis, two physicians have been disciplined. One 

has been removed as a result of the actions in Memphis. At Columbia, three senior executives have resigned under threat of discipline. 

And at Pittsburgh, as you may remember, there was a criminal 

investigation done by our criminal IG and by the Department of 

Justice. When they finished, they found that there was no criminal 

activity. In fact, they found that only one of those six patients had 

actually died from legionella and the others died from other illnesses. 

At any rate, we were forbidden from doing any further investigation or taking any action until after those investigations were finished. They finished and we’re now in the process of evaluating disciplinary action for people at Pittsburgh. 

Dr. BENISHEK. There was some other references to mismanagement not linked to deaths or discipline described as temporary 

written warnings. 

Tell me more about that. it seems inadequate, that mismanagement was not linked to deaths. What is the appropriate action for 

that type of behavior? 


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Dr. PETZEL. That is in my mind a hypothetical question. It depends on what has happened. The range of discipline that can be 

incurred is anywhere from an admonishment to removal. I would 

point out that last year, VA removed 3,000 employees, approximately one percent of its workforce. 

They over the last two years have either removed or seen resignations on threat of discipline from 14 senior executives and an 

additional number of senior executives on probationary periods 

were fired during their probationary period. 

So, sir, we do discipline our workforce. We do hold our workforce 

accountable. 

Dr. BENISHEK. It is amazing when I keep hearing this, but the 

specific instances seem to me to be a little bit more difficult. I am 

happy to hear what you have to say about those particular cases, 

but it seems from, you know, my experience that finding the person 

responsible, seems to be difficult as we talked about in the, physician staffing hearings that we had. 

Dr. PETZEL. Let me just make just a couple more comments if I 

could, Mr. Chairman. 

We have got a pretty extensive oversight system that includes 

the activities of this committee, the special counsel, the Office of 

the Inspector General, the GAO, and the Office of the Medical Inspector. These all help us determine whether or not people were accountable for the action. 

The IG investigated Pittsburgh as an example and did not find 

that there was any individual—— 

Dr. BENISHEK. Well—— 

Dr. PETZEL [continuing]. They felt was—— 

Dr. BENISHEK. Right. Well, you know, my best example of that 

to tell you the truth, Dr. Petzel, is the example of when we had 

at the physician staffing hearing. The IG over the last 30 years has 

eight times said that there should be a centralized plan for physician staffing and, yet, that centralized plan over the last 30 years 

does not exist. 

When I asked the fellow testifying, he said, ‘‘we will have a plan 

in three years’’ and, yet, I could not find out the name of the person 

who was supposed to respond to that inspector general report and 

make that plan happen. 

The IG said you need a central plan. You agreed. Eight times 

over 30 years and, yet, it did not happen. And we could not find 

out who the person who was supposed to be doing that is. This is 

the frustration that I have as chairman. 

I am over time now, but maybe we will get back to that. I would 

like to yield to Ms. Brownley for her five minutes. 

Ms. BROWNLEY. Well, thank you, Mr. Chair. I certainly want 

your question answered. 

And, you know, I wanted to just kind of follow-up as well on the 

productivity standards for specialty physicians, too. 

And if I heard you correctly, Dr. Petzel, you said that all will be 

done by March 2014? 

Dr. PETZEL. That is correct, Congressman Brownley. 

Ms. BROWNLEY. Okay. So all of them will be done by 2014. So 

then I have to assume that all of the various milestones and both 


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stage one and stage two as was laid out by you to me have all been 

completed then at this particular point in time? 

Dr. PETZEL. I would ask Dr. Agarwal to comment on it. 

Dr. AGARWAL. So, Ranking Member Brownley, you are correct. 

You know, we had stated in our testimony at that hearing that we 

will complete all specialty physician standards within three years. 

However, we have accelerated that path. 

And at this point as Dr. Petzel mentioned, we have completed 

the standards for 81 percent of our specialties and we intend to 

complete all of them this fiscal year. So, yes, ma’am, we—— 

Ms. BROWNLEY. Could you give me an idea of what the outstanding ones are? 

Dr. AGARWAL. Of the specialties? 

Ms. BROWNLEY. Yes. 

Dr. AGARWAL. Yes, ma’am. I do have a list with me. If you would 

like me to go through, I will be happy to do so. 

Ms. BROWNLEY. Well, if you could just give me a few off the top 

of your head just to have an idea of what they may be. 

Dr. AGARWAL. The ones that are remaining? 

Ms. BROWNLEY. Correct. 

Dr. AGARWAL. Okay. So we have for thoracic surgery, vascular 

surgery, cardiology surgery, anesthesia, emergency medicine, pathology amongst a few that we still need to complete. The ones that 

we have already completed are as follows: 

When I had initially testified, we had the staffing models for primary care as well as radiology and mental health was on its way. 

And I am pleased to say that the directive for mental health staffing went out a couple of months later after the hearing. 

Subsequently the standards that we have placed are for dermatology, gastroenterology, neurology, ophthalmology, orthopedic surgery, urology, as well as allergy, immunology, endocrine, and I 

have the list with me. So I would be happy to share that with you. 

Ms. BROWNLEY. Thank you very much. 

And just again as a follow-up question that once all of these are 

established, then can you explain to me how we will then measure 

sort of the accuracy and the effectiveness of these standards for all 

of the specialties that you have developed? So are you creating 

metrics for us to measure the effectiveness and the quality responses? 

Dr. PETZEL. I will let Dr. Agarwal give you some details about 

that. But just it is sort of an overview. The staffing standards look 

at the delivery of services within a department, say cardiology or 

ophthalmology, and they also blend with that the access that we 

have to those services. So we look at the access standards and we 

get a picture of the productivity of our staffing and the effect that 

it is having on the ability of people to access the care which I think 

is the ultimate thing that we are looking for. 

We want to have enough people to provide good access, not so 

many people that we are not being effective in the way we administer that program. 

And Dr. Agarwal might add anything to that. 

Dr. AGARWAL. Sure. So subsequent to the hearing, ma’am, we 

have gone ahead and we have developed many tools that will assist 

the local facilities in managing the specialty resources approVerDate Aug 31 2005 13:44 May 05, 2015 Jkt 000000 PO 00000 Frm 00013 Fmt 6633 Sfmt 6633 Y:\87-667.TXT PAT

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priately. We would like all our specialists to work at the top of 

their license which entails that they also need to have the necessary support staff so that they are able to perform their specialist 

duties in helping veterans. 

And to that end, I will reference back to the tool that Dr. Petzel 

just mentioned. It is an algorithm that links access with specialty 

productivity. All our leadership has been trained to use this tool 

and how they manage the specialty resources in the clinics and appointments. 

Ms. BROWNLEY. I think what I am trying to drive at and I think 

it is important for you as the experts to be able to evaluate the effectiveness and the quality of delivery of services, what kind of 

tools will Congress have, will the veteran community have to also 

be able to measure the quality and effectiveness of these specialties? 

Dr. AGARWAL. That is an excellent point, ma’am. So this tool has 

been currently distributed to all our facilities and they are using 

it to manage the resources within their medical centers. 

So the ultimate outcome of this is going to be better access of 

specialty services to the veterans as well as our ability to use our 

specialists most efficiently and effectively. 

To that end, we would like to share that information with Congress as and when you would like to have it. We can do that periodically at your request. 

Ms. BROWNLEY. Thank you. 

And, Mr. Chair, I yield back. I exceeded my time. 

Dr. BENISHEK. Thank you, Ms. Brownley. 

I would like to yield five minutes to Dr. Huelskamp. 

Dr. HUELSKAMP. Thank you, Mr. Chairman. I appreciate the opportunity to follow-up on some issues we have discussed in the last 

year. I appreciate your line of questioning and hopefully you will 

take that up when you return to that. 

But one thing I would like to first ask the VA is in reference to 

a year ago, approximately a year ago during a March 6 hearing, 

I asked the GAO some questions regarding the scheduling practices 

at the VA. During the course of my questioning, the GAO noted the 

dates were changed to game the system at several clinics. 

And I believe, Mr. Matkovsky, you were in attendance at the 

hearing and I asked your colleague, Mr. Shonnard, what was being 

done to prevent this from happening again and whether any penalties were imposed on the employees caught doing this. 

My question for the VA is this. Who has been held accountable 

for these actions? 

Dr. PETZEL. Before I turn to Mr. Matkovsky, Congressman 

Huelskamp, let me answer that. 

The GAO was referring to a system that we used for scheduling 

that we have since abandoned which had in it the possibilities of 

both misunderstanding of what might be scheduled and what the 

times might mean. 

We have moved to having the fundamental scheduling criteria be 

what we call the create date. And that create date is not fungible. 

That is the date that the individual calls into the medical center 

or wherever it might be and asks for an appointment. That becomes then the starting point for measuring whether or not we 


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have accomplished seeing that patient within the 14-day criteria 

that we set out. 

So that should not occur. I cannot speak to what has happened 

previously. I—— 

Dr. HUELSKAMP. Doctor, so you have abandoned the system that 

allowed and permitted employees to falsify and game the system. 

My question is, have you held anybody accountable for the actions that were identified by the GAO? 

Dr. PETZEL. I would have to go back, sir, and look to see if there 

were any disciplinary actions in those 3,000 that I mentioned that 

were specifically related to that issue. I do not know the answer 

to that question here. 

Dr. HUELSKAMP. Any of the other conferees, can you answer that 

question, whether anybody was held accountable for gaming the 

system? 

Dr. JESSE. I cannot answer the question directly because there 

are 70 some thousand people who have scheduling keys on our system. So I do not know, you know, specifically whom you are referring. 

I think the important point is—— 

Dr. HUELSKAMP. Did you follow-up with the GAO? They had evidence of that. They had identified specific instances. 

Dr. JESSE. Like I say, I cannot give you the specifics on that. 

Dr. HUELSKAMP. No one here followed up on the GAO? And you 

saw this report yesterday suggesting that is going on elsewhere in 

the system in which the VA purged thousands of medical tests, this 

is just yesterday’s article, to game its backlog stats. 

So first question, follow-up of the GAO report, it was just ignored 

then? 

Mr. MATKOVSKY. No, Congressman Huelskamp. I went back and 

asked some of our team to identify, if we could, the allegations that 

were presented by the GAO during that hearing. We were not able 

to find concrete evidence that the GAO had and they did not actually give us the specifics so that we could go to the individual and 

find it. 

So we did follow-up. We could not find the concrete evidence to 

engage an appropriate disciplinary action, sir. 

Dr. HUELSKAMP. So you just abandoned the system and those 

employees that were followed up? 

A little more on the GAO. So the GAO made allegations and you 

never reported back to the committee that I am aware that GAO 

was mistaken or provided no evidence of that. I have appreciated 

the product from the GAO and you are saying here they had no evidence of that? 

Mr. MATKOVSKY. That is not what I am saying. I am saying that 

we did not have independent evidence outside of the GAO report 

that could identify an individual who engaged in the—— 

Dr. HUELSKAMP. Well, where did they come up with that, sir? 

Mr. MATKOVSKY. They had their evidence. 

Dr. HUELSKAMP. Their evidence is from your system. 

Mr. MATKOVSKY. That is correct, sir. 

Dr. HUELSKAMP. So their evidence was inaccurate? 

Mr. MATKOVSKY. It was interview based, if you recall, so they 

had a series of clinics that they visited and then they went through 


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and monitored the behavior. They measured that behavior against 

the policy and they identified that someone instead of selecting the 

desired date of the veteran, they were asking the veteran when 

they wanted to be seen and using that as the desired date. 

So they were monitoring behavior specifically and we were attempting to find evidence of that on our own and we could not. 

Dr. HUELSKAMP. And, lastly, any responses to this report again 

of gaming the system that came out yesterday? Apparently any request for documents describing when the practice began or how 

many employments have been cancelled was refused. 

Dr. PETZEL. That was almost what I would call a scurrilous 

newspaper report. Several years ago, the West LA Greater Los Angeles healthcare system embarked on a very carefully thought out 

review of past requests for consultation or x-rays in the imaging 

department to see if indeed there were requests that had not yet 

been closed out. 

They identified 300 requests that had not been closed out. They 

had not been closed out because the patients had moved, because 

the patients had failed to show up for the appointment or repeat 

appointments. 

There was nobody who needed the care that was denied the care. 

There was no attempt to eliminate a backlog by destroying records. 

You cannot destroy the records. They are electronic and they are 

there forever. 

Dr. HUELSKAMP. But they were administratively closed, is 

that—— 

Dr. PETZEL. They were administratively closed. 

Dr. HUELSKAMP. And according to the article, it is not a few 

thousand. It is 40,000 in LA and 13,000 in Dallas. And I appreciate 

it. 

One last thing. It does say in the article, and I would like to follow-up on each of these, Mr. Chairman, if I might, it says performance reviews and bonuses of top hospital administrators are linked 

to meeting those goals. I would like to see if there is a connection 

like that as indicated in the article. 

I yield back, Mr. Chairman. 

Dr. BENISHEK. Thank you, Mr. Huelskamp. 

Ms. Negrete-McLeod. 

Ms. NEGRETE-MCLEOD. [Nonverbal response.] 

Dr. BENISHEK. Dr. Ruiz. 

Dr. RUIZ. Thank you for being here. I thank you for your service 

and thank you for all your hard work. 

We definitely have to continue your efforts. There is a lot of problems that we need to fix and I appreciate that we are moving in 

the right direction albeit it perhaps impatiently slow, but we have 

to continue to move in that direction. 

You know, Mr. Matkovsky, I wrote a letter to you dated February 6 about procuring three ultrasound machines for my regional 

VA hospital. They have been waiting for a long time to get three 

simple ultrasound machines. 

When I was in Haiti after the disaster as the medical director 

for the largest internally displaced camp in Port-au-Prince with 

about 60,000 Haitians living under sheets and sticks in the midst 


VACREP180 with DISTILLER
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of our western hemisphere’s most severe disaster, we needed 

ultrasound machines. 

And I made a phone call to a local hospital in my area. Two 

weeks later, we get an ultrasound machine. And you talk about 

logistical nightmares. You talk about bureaucracy. You talk about 

the difficulty in transporting ultrasound and getting the right one, 

et cetera, to an earthquake stricken country. 

Why does it take so long to get those ultrasounds? Two, when 

can we get those ultrasounds? 

Mr. MATKOVSKY. Thank you, Congressman Ruiz. 

That letter is actually being responded to by Mr. Frye. He is our 

senior procurement executive as well. I think it was co-addressed. 

If I may, I may just address a little bit of the consolidation process that we have historically used in VA. We have a national acquisition center that has all of our national contracts for what we call 

high cost medical equipment. The high cost, high tech ultrasound, 

MRIs, CT scans, et cetera, are all acquired through that central 

service. 

What we have typically done historically is we consolidate our 

purchases. We did that under the premise that through consolidation, we would achieve better price competition and then achieve 

some measure of return. 

We have looked at that process in 2012. At the end of 2012, our 

consolidation was 909 pieces of equipment. These ultrasound machines were part of that consolidated purchase. We expect to finish 

all of the delivery orders for those by April of this year. 

So in answer to your question, the delivery orders, if they have 

not been issued, will be issued by April. 

Now, we are looking at that process and figuring out how we can 

do it a little bit faster and a little bit different. 

Dr. RUIZ. Can I ask you a question there? 

Mr. MATKOVSKY. Yes. 

Dr. RUIZ. You said delivery orders. My goal is the end goal, the 

actual outcome. So tell me the time it takes between delivery order 

and then actually the Loma Linda VA receiving the ultrasound. 

Mr. MATKOVSKY. Sir, I do not have an answer for that. That 

would depend on the manufacturer that gets the ultimate delivery 

order, but it can be as quick as three months or less depending 

upon the manufacturer. 

We ran a separate process. Let me just—I can see your expression, sir. So we ran a separate process as a result of our roundtable 

which Chairman Benishek and Ranking Member Brownley held. 

And we carved out some different cost items, portable x-rays, Carms, and we ran those at the network level in VISN 15 which is 

the heartland of the country, Missouri. 

And those that we purchase through that process from the beginning of the requirement through the actual contract award was 90 

days, right, as compared to 400 or so days for a consolidated process. That equipment began arriving, the portable x-rays began arriving before the end of calendar year 2013. Start to finish, less 

than six months. 

Not exactly the same as your Haiti example, but considerably 

faster. We are going to try that again in Network 23 just to make 

sure we can iron out some of the kinks and we are going to use 


VACREP180 with DISTILLER
14 

that process system-wide from here on out once we finalize just a 

couple of details. 

We hope that is going to speed it up a lot and then we are also 

going to look at the consolidation process and change that as well. 

Dr. RUIZ. Thank you very much. 

I am going to continue to follow the natural life history of requesting three ultrasound machines until they are born in the 

womb of our Loma Linda VA Hospital. So, you know, thank you so 

much and I will follow-up with you. 

Dr. BENISHEK. How long has it been that this is going on? 

Dr. RUIZ. How long has it—it has been two years, my friend, two 

years for three ultrasound machines. 

Dr. BENISHEK. All right. 

Mr. MATKOVSKY. It is too long, I agree. 

Dr. RUIZ. Thanks for that. 

Dr. BENISHEK. Five minutes for Dr. Wenstrup. 

Dr. WENSTRUP. Thank you, Mr. Chairman. 

I appreciate you all being here today. 

And forgive my ignorance on my first question, but I am curious 

if any of you have ever as doctors been in private practice where 

you ran your own business. Have any of you been in private practice? 

Dr. PETZEL. I have not. I have worked in academic medicine, but 

not private practice. 

Dr. WENSTRUP. Okay. Because this is where I draw the line on 

so many things. For example, if the VA hospitals and their providers operated under Medicare rates, for example, or even, say, 

105 percent of Medicare rates and providers were paid fee for service, do you think the VA hospitals would be in the black? 

Dr. PETZEL. Yes, personally I do. We have done several studies 

going back as many as ten years and looked at our cost to providing a service as opposed to the private sector cost of providing 

a service or compared to the Medicare reimbursement. And in virtually every instance, we are talking 15 to 25 percent less cost associated with providing that service. So, yes, I think we could survive very well on Medicare rates, very well. 

Dr. WENSTRUP. Because there is a part of it sometimes that 

makes me curious as to what motivates the VA system, the way 

it is funded, et cetera, to really be effective and efficient compared 

to, say, private practice because I have operated under both systems. 

And besides personal pride in the work that I do and besides motivated to try and see as many patients as I possibly can effectively, those are personal things, but what within the system motivates that? 

For example, because I found, and I will use DoD as an example, 

as a reservist in private practice, in the time that I would see 45 

patients effectively and efficiently in my private practice because of 

the way military hospitals are set up and the physician staffing, et 

cetera, I could only see 15. I mean, that is just a fact. 

And I have offered to you in the past to come into the VAs and 

work with you on the staffing issues. And I have not heard anything from anybody on that, and I mentioned it to Secretary 

Shinseki as well. 


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So what within the system motivates, stimulates the entire system to be extremely effective and efficient? What does that? 

Dr. PETZEL. Well, thank you, Congressman Wenstrup. That is an 

excellent question. 

First of all, it is the mission. I mean, we are taking care of people 

who have earned and deserve the care that we are delivering. 

The second thing is that we have an unlimited demand on the 

service with a limited budget. We do not generate more money if 

we do more work. We get our budget at the beginning of the year 

and we have to take all comers because of that. That has driven 

tremendous efficiencies in this system, tremendous efficiencies. We 

roll by one to 1.5 percent in terms of the number of people we treat 

every year. 

Our models for funding have in them productivity standards 

which say that we have to increase our productivity by one to two 

percent every year. That is a tremendous, tremendous motivator. 

I would match our efficiency and our cost of doing business against 

the private sector at any time. 

Dr. WENSTRUP. Okay. In the effort that you are making with providing appropriate staffing, you know, in our private practices, are 

we increasing our staffing so that we can treat patients more effectively, increase access, things like that as well as have good outcomes? You know, there is a real number value to that. 

So are you doing a follow-up on that that will show, yes, we are 

now seeing more patients at least cost and being efficient and will 

we have access to those types of numbers? 

Dr. PETZEL. I would ask Dr. Agarwal to comment on that. 

Dr. WENSTRUP. Sure. 

Dr. AGARWAL. This is an excellent question, sir. And that is exactly what we recently asked since we have provided these tools to 

our local managers in managing these resources as to how it is that 

they are using it to make the clinics much more efficient and ensure that all the specialists are working at the top of their license. 

And the information that we have gotten back has actually been 

very good. Managers are looking at the resources that they are providing to the clinics and understanding what is the output, what 

is the value that they are achieving I think was made possible by 

these tools. So to be able to tell a specialist that you need to spend 

more time in the clinic or take care of, certain groups of patients 

has been possible because now when the access data and the productivity is aligned and it is sort of placed in a way that people can 

understand much better, it gives you insight into whether additional resources are needed or enough resources have already been 

provided but some other changes need to be made in specialty clinic. So we believe that in the longer run once this becomes the norm 

in how we practice, especially with the resource management part, 

this is going to be extremely beneficial. 

Dr. WENSTRUP. Yes, I think it can be. I mean, assuming you are 

going to see everyone eventually that needs care we actually have 

a tremendous savings if we see them sooner and do it more efficiently and effectively. So you want to make sure that when you 

add a staffer it is because you get a better result and better outcomes. 

Dr. AGARWAL. Exactly. Exactly. 


VACREP180 with DISTILLER
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Dr. WENSTRUP. I think that is what we want to hear back from 

you on over time as this is implemented. 

Dr. AGARWAL. Thank you. 

Dr. WENSTRUP. Thank you, and I yield back. 

Dr. BENISHEK. I just want to comment for a moment. Dr. Petzel, 

that answer you just gave Dr. Wenstrup, that is just completely ridiculous. 

Dr. PETZEL. I am sorry? 

Dr. BENISHEK. You know, I worked at VA? In order to get the 

number of cases that I had done in the private sector in VA it took 

me a year to get the staff up to speed so I could do the same 

amount of cases at VA that I could do in the private sector. Motivating the staff at a VA hospital to get things moving and to use 

your time effectively is a tremendous, tremendous problem. And 

that answer that you gave, that said that you would put VA up 

against the private sector anytime, that is a complete fabrication 

of what actually occurs at the VA. I worked at VA for 20 years. I 

know that that is just not true. And having people from the outside 

who have been in the private sector whose time is valuable sitting 

in the doctor’s office doing nothing for a half a day with you, a 

turnover time of a half an hour which is done in like seven minutes 

in the private sector is very frustrating to physicians. That kind of 

answer is not going to wash it here. With that I am going to give 

Ms. Kuster an opportunity to ask a question. Thank you. 

Ms. KUSTER. Thank you very much, Chair Benishek, I appreciate 

it. And thank you to Vice Chair Brownley for your leadership on 

these issues. I have two questions, if I could. One has to do with 

a company in my district in New Hampshire, Salem, New Hampshire, the company is named Gamma Medica. And they make a 

medical device that produces bone density imaging to help with 

early detection of breast cancer. And my question is not specifically 

about them but my understanding is in New England many of our 

VA health facilities have requested this life saving device but due 

to over two-year-long delays many veterans seeking early breast 

cancer detection are not receiving the treatment that they, delays 

at the NAC. And my question, this is to Dr. Petzel, can you tell 

me how VA is actively engaged with improving delays for new technology at local facilities? And what steps have you taken since the 

round table last April on procurement wait times that we had to 

work with NAC on improving the amount of time it takes to deliver 

lifesaving devices? 

Dr. PETZEL. I would defer in a moment to Mr. Matkovsky who 

has gone through that. But just to say that we are, we are not 

happy with the two-year process as well. The bundling, from my 

personal perspective, puts delays on this acquisition that I think 

are unnecessary. There is a compromise here between trying to 

save money by bundling on the one hand and on the other hand 

delaying the acquisitions because we are bundling. But Mr. 

Matkovsky, why do you not just go through again what you had 

said about what we are trying to do to reduce that time? 

Mr. MATKOVSKY. Yes, sir. 

Ms. KUSTER. Thank you. And I apologize that I had to come in 

late. 


VACREP180 with DISTILLER
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Mr. MATKOVSKY. No, that is okay. Congresswoman Kuster, the 

one thing I would state is that in our efforts to establish a structure that was more economical we left out a critical variable in history, which was speed. Our supply chain should also focus on 

speed. Procurement reform should establish compliant, economical 

acquisitions, but they should also be fast. 

Following our round table we did review how we do the consolidations. We are trying to change those. It is going to take us a little bit of time. The big focus was the end of fiscal year 2012 orders 

that went in. There were 900 of those. The bone densitometers for 

Gamma Medica may in that consolidated process. But it is not a 

process that is working in terms of speeding the new technology for 

application. What we are trying to do now is move the less complex 

items so that they can be purchased at our 21 network offices 

through their contracting officers. In a sense instantaneously you 

have 21 additional work teams now focusing on it rather than just 

the one up in Chicago. 

We wanted to make sure we could test it. We found out that 

there were some clauses that were competitive with our national 

contracts. We are going to extend the test a little bit more and then 

beginning in fiscal year 2015 that will become that way of business. 

That will free up these national acquisitions to be a little bit faster 

as well. 

By April of this year we expect to be finished with all of the delivery orders from that last major consolidation. Then it will still 

take some time for the technology to be in medical center. 

Ms. KUSTER. Okay. Thank you very much. My other question has 

to do with an issue that many of us have been involved with in the 

past year on military sexual assault treatment. I have been visiting 

the VAs in White River Junction and in Manchester and have actually been quite impressed by the protocols there but I am not familiar across the country. 

We had a hearing last July where we had some very compelling 

testimony from veterans. And we were talking about whether veterans are being adequately screened for military sexual trauma. I 

think if I recall the testimony they were only asked on the initial 

visit and they were not asked on subsequent visits. So I would like 

to hear how the VA is following up with the local VA health facilities to measure the effectiveness of screenings and follow ups and 

also how are you providing local smaller VA facilities the information and tools they need to train and educate providers to treat survivors of MST? 

Dr. PETZEL. Dr. Jain was at that hearing, as you remember. And 

I would ask him to comment on the changes and improvements we 

have made since then. 

Ms. KUSTER. Great. Thank you. 

Dr. JAIN. Thank you, Congresswoman Kuster, for that question. 

So as you mentioned this was fairly compelling testimony that we 

heard last year. So we have taken several steps. First of all the entire screening has now been revised. So that questions are being 

revised. We believe that the questions were not very clear before 

so we added a little more clarity. We have also added an option 

where the veteran could decline to answer the question. So they 

could answer the question whenever they felt they were ready, and 


VACREP180 with DISTILLER
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to whom they felt comfortable with answering the question. So if 

the veteran were to decline to answer the question, then within the 

year the reminder would kick back in and the question would be 

asked again so we do not lose that opportunity. 

Ms. KUSTER. Oh, that sounds good. Instead of people assuming 

that that is a no answer—— 

Dr. JAIN. Yes, ma’am. 

Ms. KUSTER [continuing]. It is a decline answer and then you 

would revisit it? 

Dr. JAIN. We will revisit that. We will also have added actually 

a functionality where a third question has been now added. 

Through the pilot we learned that the veterans want to be referred 

to mental health or to specialty care and now we will be able to 

track those referrals and will be able to follow up through our data 

and numbers to see how the individual facilities are doing with following up on the reminders. 

Ms. KUSTER. That sounds great. And could, I do not know if this 

would be possible to add to your protocol but I just want you all 

to be aware and maybe there is a way it could be factored in, we 

were successful in passing a bill to provide whistleblower protection 

to members of the military who come forward with claims of sexual 

assault, men and women. And I think it is an important piece of 

information because of the history on this issue and because of the 

retribution and retaliation in some cases in people’s careers, that 

there was good reason not to come forward. And so I am hoping 

that you will find a way to incorporate this, to reassure victims to 

come forward that this whistleblower protection will be in place. 

Dr. JAIN. We can certainly look into that, Congresswoman, and 

see how we could incorporate that. 

Ms. KUSTER. Thank you. Thank you very much. Thank you, Mr. 

Chair. 

Dr. BENISHEK. Yes. I am going to start another round of questions, and I have got a couple of things. Dr. Petzel, would you provide the committee for the record the circumstances surrounding 

the 14 SES employees you said the VA forced to step down in the 

past two years? We would like to have that by the end of the week, 

if we could. 

Dr. PETZEL. If I could clarify that, Mr. Chairman. Let me clarify 

that, sir. I had the numbers wrong. There were 14 serious disciplinary actions taken. Six SES employees were dismissed over the 

last two fiscal years, three non-probationary, and three first-year 

probationary. And we will provide whatever information you want 

related to that. 

Dr. BENISHEK. All right. All right, thank you. I am going to go 

back to one of the hearings that we did in the past to follow up. 

It is concerning the care and treatment of military sexual trauma 

and I think Dr. Jain was the, primary witness at that hearing. And 

I just want to follow up a bit more. You said we are going to take 

a critical look at how we structure services and what we can do to 

address some of the gaps. And you also said, ‘‘I think there are 

many points that the veteran witnesses made in terms of suggestion that we would take to heart, and we will go back and review 

our current policies and procedures.’’ So Dr. Jain, what specific actions have you taken to improve the situation? You mentioned, the 


VACREP180 with DISTILLER
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questioning or the asking about sexual trauma. But what else specifically have you done to address the concerns that we brought up 

in that hearing, and that were brought forth by that testimony? 

Dr. JAIN. Thank you, Mr. Chairman, for that question. So as I 

was just stating to Congresswoman Kuster, so the first big thing 

we did is to do a careful analysis of our screening process. And as 

I was indicating earlier—— 

Dr. BENISHEK. All right. You went through that. But go through 

something else. 

Dr. JAIN. So that was number one. Secondly, we have also looked 

at our outreach activities that we are doing. So we have modified 

our outreach posters where the male and the female, survivors are, 

included in the posters. We are also doing outreach with the Department of Defense so that at the time of transition this is an activity we have taken in the last few months. So as the 

servicemembers transition from DoD to the VA the information regarding MST services is now provided to them so they know and 

they understand what services will be available to them in the veteran status. So that is an improvement. 

We have also taken education and training activities. So we have 

trained the MST coordinators on the sensitivity relating to the 

male survivor issue that was presented at the hearing. We want 

to make sure that our male survivors can receive care in a gender 

sensitive manner in our outpatient clinics so they do not have to 

go for a women’s clinic, for example, to receive services. 

We have also made sure that the—— 

Dr. BENISHEK. That change has occurred, then, you are saying? 

Dr. JAIN. Yes, sir. That training has already occurred. We have 

also trained the VISN leads that provide the MST services to monitor that activity. We also make site visits. And so we are tracking 

this as part of the site visits to make sure the facilities are providing the care in a gender sensitive manner. And then we are also 

doing a mystery shopper type sort of activity where both the male 

and the female staff members would call, randomly call the VA facilities to speak to the MST coordinator to just understand how will 

it take them to reach an MST coordinator, whether they are able 

to address the questions in a sensitive manner. So these are all the 

changes—— 

Dr. BENISHEK. How is that working out? 

Dr. JAIN. That is actually going quite well. We have been very 

pleased with the training and how that has taken hold. 

Dr. BENISHEK. Well I would like to see a report on what you—— 

Dr. JAIN. Yes, sir. We can certainly. 

Dr. BENISHEK. That is a great idea, I think. Having somebody 

just call in anonymously and figure out what is actually happening. 

So if I could get a report on that, I would like to see that. 

Dr. JAIN. We would be happy to—— 

Dr. BENISHEK. How many times you called, the response, all of 

that. I appreciate your answer there. I think I will yield to Ms. 

Brownley. I want to keep the questions coming. Thank you. 

Ms. BROWNLEY. Thank you, Mr. Chair. You know, I wanted to 

also follow up on the military sexual trauma issue as well. You 

talked about the outreach that you are doing and thanks to the 

chairman we had a hearing in my district last week talking about 


VACREP180 with DISTILLER
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mental health services but a component of that discussion was 

about outreach. And one of the problems that was discovered in the 

various testimony is that the West L.A. facility was doing the outreach for mental health services for Ventura County, and Ventura 

County was not providing the outreach. And it was clear that the 

West L.A. facility was not aware of all of the programs that were 

accessible to programs in the county. So their outreach is basically 

ineffective because they have no idea about all of the nonprofits 

and volunteer organizations and so forth that could help our veterans. So when you talk about outreach for the, for our victims, or 

survivors I should say, of military sexual trauma, what does that 

outreach really look like? And I know that the IG had recommended and thought it would be very, very beneficial to have a 

central sort of program resource list that would be, at every VA 

medical clinic or in every community-based outpatient clinic, across 

the country. So if you could respond to that, please? 

Dr. JAIN. So thank you, Ranking Member Brownley. I think 

there are a couple of things that we have done so I may not have 

a complete answer for you. But part of the outreach, as I mentioned earlier, is with our Department of Defense colleagues. But 

the other part of the work that we have done is reached out to 

OEF/OIF counselors within our own system. As you know, within 

the VA the majority of the outreach work in the communities is 

done by our OEF/OIF counselors. So our MST team has now 

trained the OEF/OIF counselors to begin to do the kind of outreach 

that you are referring to so that we can reach out into the community with nonprofits and also with other types of resources that are 

out there. So I cannot honestly say to you that it is completely 

functioning. But this is part of the process that we are now beginning to go beyond just the DoD into the community. 

Ms. BROWNLEY. Thank you. And I also wanted to get a clarification in the testimony. Dr. Petzel’s testimony indicated that the VA 

established a benchmark of .2 full time equivalent employees per 

100 veterans who screen positive for MST. So help me to understand what that means. Is that the equivalent of a full FTE per 

500 veterans affected by MST? 

Dr. JAIN. So thank you, Ranking Member Brownley, for that 

question. So the process, the way it works is that in our Office of 

Productivity and Efficiency we have created a tool that monitors 

the numbers of MST survivors that we are treating and the staff 

resources that are dedicated to treat this MST survivors. So from 

that tool what we have determined is that it takes on an average 

two staff per thousand, or 0.2 per hundred. The staff would include 

all of the mental health staff, not just a particular staff member. 

So those facilities, so the last report that we have available is for 

fiscal year 2012. For fiscal year 2012 99 percent of the facilities 

met that staffing standard. There was only one facility that fell off. 

So after the hearing we immediately got after that particular facility, developed an action plan, and since then they have made the 

corrections. The fiscal year 2013 report would be available within 

the next few weeks. And we will be able to see how the facilities 

are doing to these staffing standards. 

Ms. BROWNLEY. Okay. Well we would certainly like to see that 

report. It is hard for me to comprehend honestly that when we 


VACREP180 with DISTILLER
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have a veteran who is in dire need and who is experiencing very, 

very deep trauma that a .2 FTE is adequate. And I know you said 

that is from a variety of services, but kind of culled together it 

equates to a .2 FTE correct? 

Dr. JAIN. So let me clarify again, Congresswoman. This is at a 

larger data trend issue. But for that individual veteran, we will 

provide them whatever services they need through our mental 

health clinic. Now what we emphasized right after the hearing, as 

you recall, some of our witnesses were very concerned that when 

the VA was not able to provide the care in a timely manner that 

we did not refer them to a non-VA care. So we continue to emphasize to our staff that non-VA care is an available option. And I 

think as Dr. Petzel said PC3 and the availability of PC3 that would 

happen starting April and beyond will make it easier to reach out 

to community providers. So for individual veterans the .2 issue 

does not apply. This is for monitoring purposes that we keep track 

of what staffing resources are being dedicated to provide the services. 

Ms. BROWNLEY. I am just, so if that is the benchmark of what 

you are going to measure, then it is hard to measure that a veteran 

who, again, is in deep trauma in the moment that they need our 

help, if they have gotten all of the resources, because your measurement is going to be, you know, a .2, sort of a, kind of a across 

the board in the aggregate. So you know, it is, I am not sure that 

that is a good metric. Maybe I need to understand the metric in 

further detail. But I think we are all most interested, you know, 

in the, obviously the screening part that you have talked about. 

But when, you know, when we have a veteran who has gone 

through this kind of trauma and needs our help in that moment, 

you know, it takes a lot of, I think a lot of attention and a lot of 

support. So it does not translate for me. 

Dr. PETZEL. Just if I could respond a little bit to that, Congresswoman Brownley. The metric looks at the system overall, that. We 

would be evaluating the effectiveness of caring for individual patients through a variety of different ways. I am not familiar exactly 

with what we do in military sexual trauma. But as an example 

with depression, they would take a survey beforehand, they would 

take a survey after one year that they have been treated to look 

at their score on a depression scale. Those are the kinds of 

things—— 

Ms. BROWNLEY. A survey which is to ask veterans—— 

Dr. PETZEL. Yes. 

Ms. BROWNLEY [continuing]. How the VA responded to their 

needs? 

Dr. PETZEL. Exactly. Or how did they feel. 

Ms. BROWNLEY. Right. 

Dr. PETZEL. The Beck Depression Scale measures your level of 

depression. I am just using that as an example. That is the kind 

of thing that we would use to measure the effectiveness of what we 

are doing. Not this metric of, this is just a gross way to say the 

facility appears to be devoting in the aggregate the resources needed. But you are absolutely right. We need to look—— 


VACREP180 with DISTILLER
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Ms. BROWNLEY. But the report, I am sorry, may I just have one 

more second? But the report you are saying that was in 2012 and 

we are going to get in 2013 is a measurement based on this metric? 

Dr. PETZEL. Correct. 

Ms. BROWNLEY. Not a survey of veterans who are survivors of 

military sexual trauma and how the VA responded to them? 

Dr. PETZEL. Correct. 

Ms. BROWNLEY. That data we will not get? 

Dr. PETZEL. Not in that 2013 report. But Dr. Jain and I will talk 

about what we can do to provide you with information about the 

effect of what we are doing. 

Ms. BROWNLEY. I yield back, Mr. Chair, thank you. 

Dr. BENISHEK. Thank you. Mr. Huelskamp? 

Dr. HUELSKAMP. Thank you, Mr. Chairman. If I might, I would 

like to follow up on a few of your questions and drill down some 

of the accountability issues with employees and these preventable 

deaths which have I guess been confirmed by the VA to committee 

staff. But in the Columbia, South Carolina, which were six preventable deaths, were there any employees held accountable for those 

preventable deaths? 

Dr. PETZEL. Well first of all, the concept of preventable deaths 

I think requires some discussion, not here. Yes, there were. There 

were three employees at senior levels who resigned—— 

Dr. HUELSKAMP. Resigned or—— 

Dr. PETZEL [continuing]. Under threat of discipline. 

Dr. HUELSKAMP. But they were not disciplined? Is that, they 

left—— 

Dr. PETZEL. They left before they could be disciplined, correct. 

Dr. HUELSKAMP. So perhaps, and I guess we are arguing about 

whether they were preventable deaths, they were allowed to resign 

and move on—— 

Dr. PETZEL. Allowed to resign? It is their right to retire or resign. 

Dr. HUELSKAMP. There is no way to hold them accountable when 

people die because of their failures? 

Dr. PETZEL. If somebody wishes to retire or resign, we cannot 

prevent that from happening. 

Dr. HUELSKAMP. There is no way, no criminal investigation, 

nothing along those lines to hold these former VA employees accountable? 

Dr. PETZEL. There is no criminal, there was no criminal charges 

or intent involved in any of these situations. 

Dr. HUELSKAMP. And then the three deaths at the Augusta, 

Georgia center? I do not know if you answered that. Was anyone 

held accountable for those three preventable deaths? 

Dr. PETZEL. We had a similar situation where a number of people 

have either retired or resigned. 

Dr. HUELSKAMP. And of course I would hope you could provide 

that information to the committee within 30 days. The other one 

that I did not see was the VA Pittsburgh system with Legionnaires’, and we had a hearing and it was just a shocking hearing 

to me. I guess it is arguable in your mind how many veterans died 

as a result of that, but you did indicate at least one actually died 

of Legionella. Was any VA employee held accountable for the failures that led to this death? 


VACREP180 with DISTILLER
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Dr. PETZEL. Yes, as I said earlier Congressman Huelskamp, we 

are in the process of evaluating the disciplinary action taken at 

Pittsburgh. It was delayed because of the criminal investigation, 

which did not allow us to do anything. 

Dr. HUELSKAMP. So you had a criminal investigation there, but 

you did not pursue that, no one pursued that at Columbia where 

there were six preventable deaths? 

Dr. PETZEL. The IG pursued a criminal investigation. There was 

no indication, nobody raised the question of whether there was 

criminal intent at any of these other facilities. 

Dr. HUELSKAMP. The preventable death, at least the one that you 

confirm here, when did that occur at the Pittsburgh VA Center? 

Dr. PETZEL. One moment, sir. July 12, 2012. 

Dr. HUELSKAMP. How quickly do you expect, the criminal investigation is complete or not and when will you move to some accountability action? 

Dr. PETZEL. Criminal investigation by the criminal IG is complete. They found no criminal activity or intent. And I am hoping 

that very quickly we will have the evaluation of disciplinary action 

at Pittsburgh concluded and we will know what we are going to do. 

Dr. HUELSKAMP. Okay. I look forward to that report. And lastly, 

at the Atlanta VA Medical Center the Inspector General linked 

three preventable patient deaths to widespread mismanagement. 

Yet we heard that the Medical Center Director maintained no employees responsible for the mismanagement linked to the deaths 

should be fired. Is that still the case? 

Dr. PETZEL. Well first of all the IG did not link any deaths to 

the activity at Atlanta. There were three mental health deaths but 

the IG made no comment in their report on the quality of care that 

was delivered to them or the course of action. And seven people at 

Atlanta have been disciplined in various ways as a result of that 

activity. 

Dr. HUELSKAMP. The IG’s report I thought linked that to mismanagement issues. You are saying it did not but you disciplined 

someone anyway? 

Dr. PETZEL. Yes, specifically the IG said that there had been mismanagement of the contract for contract mental health services 

and there had been mismanagement on the mental health ward. 

They did not link any deaths to those activities. 

Dr. HUELSKAMP. But you do say that seven employees have received some type of disciplinary action. Last we had heard in the 

Fall it was three employees received temporary written warnings. 

Can you describe the seven, the actions of the seven employees that 

were held accountable? 

Dr. PETZEL. Congressman Huelskamp, I do not have the specifics 

of what happened with the seven but we certainly can provide that 

generically to you. 

Dr. HUELSKAMP. Well I would like it, rather than generic I would 

like it answered obviously—— 

Dr. PETZEL. Well we cannot name the individuals but we can tell 

you exactly what was done. 

Dr. HUELSKAMP. Oh, absolutely. But again, last Fall this committee was told there was temporary written warnings for three inVerDate Aug 31 2005 13:44 May 05, 2015 Jkt 000000 PO 00000 Frm 00027 Fmt 6633 Sfmt 6633 Y:\87-667.TXT PAT

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dividuals and so I would like clarification. Apparently you have 

done some more since then. 

Dr. PETZEL. There were, yes, at the time of the previous hearing 

there were three actions that actually had been taken and there 

were four actions pending. All have been now taken. 

Dr. HUELSKAMP. Okay. I look forward to that report. Thank you, 

Mr. Chairman. 

Dr. BENISHEK. Thank you, Mr. Huelskamp. Dr. Wenstrup. 

Dr. WENSTRUP. Thank you, Mr. Chairman. You know, I appreciate all of your level of expertise and your medical backgrounds. 

But to be honest I am a little surprised that there is not people 

involved with administration that have been in the private sector. 

I think it would be extremely helpful. And I did not come to Congress to sit here and to complain about things but to try and bring 

solutions. And that is the drive of my efforts here. 

Let me ask you Dr. Agarwal a question on, for example, in an 

eight-hour day in the VA system on average how many patients 

would an orthopaedic surgeon see? 

Dr. AGARWAL. Sir, you know, that would be hard for me to sort 

of say. If it is an outpatient clinic I would assume that—— 

Dr. WENSTRUP. I am talking about in the outpatient clinic setting. Assuming their surgery day is different, we can get to that 

later. But just in an eight-hour day, in the outpatient clinic, doing 

their post-ops, etcetera, how many patients do they see on average? 

And if you do not know, that is okay. 

Dr. AGARWAL. I actually do not know. 

Dr. WENSTRUP. Okay. See, this is the type of thing I am talking 

about when I am talking about measuring productivity. And you 

say you have been doing this, and we have talked about it for the 

last year, and you do not have an idea. So what are you measuring? Because I was operations chair for a 26-doctor orthopaedic 

group. These are the things we looked at and how do we improve 

our staffing so that we can be more productive and still provide the 

care. And our reputations are on the line with this, too. So it is important. So I would like to know what type of metrics you are going 

to use, and that goes back to my previous question before. And I 

am not trying to be a pain. But are you going to do something that 

is effective and efficient. And if you do not know those numbers 

then you do not even have a baseline to start with. 

That being said, let me go back to where Dr. Benishek weighed 

in having his experience at a VA and your comments to Dr. Petzel. 

You know, I am just curious to know if a VA hospital budget was 

based on the previous year’s activities submissions at a Medicare 

rate, fee for service. If that was your budget based on your previous 

year’s productivity, based on Medicare rates, you say that yes you 

would be in the black. So it would be interesting to know if that 

actually would cost the taxpayers more or less, if that is how your 

budget was based. And based on your comments it almost sounds 

like that would come in less than what we actually budget for you. 

And so would you be comfortable exploring that notion? 

Dr. PETZEL. Certainly. 

Dr. WENSTRUP. Thank you. And I yield back. 

Dr. BENISHEK. Thanks, Dr. Wenstrup. I have another question 

and I am just trying to cover the issues that we have covered over 


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the last year, and one of them is the third party billing issue that 

we had talked about. Perhaps Mr. Matkovsky can answer this. Can 

you tell us about what is happening since you gave us the testimony there? Are you, are you collecting better? Have you changed 

anything since I talked to you last? I have got a couple of follow 

ups, too. 

Mr. MATKOVSKY. Yes, sir. We covered two topics there. One of 

them was non-VA medical care. And if you want I can give you a 

little update on where we are with—— 

Dr. BENISHEK. Well let us start with the collection—— 

Mr. MATKOVSKY. Yes, sir. 

Dr. MATKOVSKY [continuing]. Because that is what we are here 

for. And then for collections, as a result of that round table discussion we had public requests for information, which is a precedent 

to a request for proposals, to look at are there industry systems 

that would allow us to automate the billing process a little bit better. When we analyzed the turn around time for billing we noticed 

that one of the longest times that it takes us is actually from the 

outpatient event, the inpatient event, to the generation of the bill. 

And a lot of that is because of the manual process. So we had a 

competitive RFI, request for information, and we are evaluating 

those responses. We are also working with our IT organization to 

determine whether or not the systems enhancements would be considered IT and subject to that funding or whether we could use 

them under administrative funds. 

Dr. BENISHEK. All right. Okay. Well I think that gives me an 

idea of where you are at. 

Mr. MATKOVSKY. Yes, sir. 

Dr. BENISHEK. The only other question, I know you talked about 

this PC3 thing and you kind of led me to believe that this is going 

to help solve the problem of getting outside care to our veterans in 

a more timely fashion. But my concern frankly is two things. The 

reimbursement rate that providers are going to be provided 

through VA. And like sort of what is the take from the insurance 

people? What percentage of the total spending is going to be made 

to get these third party networks on board? Can you tell me about 

that? 

Mr. MATKOVSKY. Sure. First I would tell you that we kicked it 

off in January on time. There was a little bit of a delay, but it is 

now running. It is in 47 of the initial 50 medical centers are referring patients through to the PC3 networks. There are somewhere 

north of 5,000 referrals that have been made to the network. I will 

tell you that our agreement, however, is with the intermediaries 

not with the firms themselves. So we have an agreement with 

TriWest, we have an agreement with Health Net organizations, not 

with their provider networks. However, both contractors are required by their contract to have a built out network for us. So the 

incentive for them is to have as competitive a network as they can 

for us to provide them referrals, and that is actually by the basis 

of the contract as well. 

Dr. BENISHEK. But the question I asked was the reimbursement 

to the providers, what level is that going to be at? And what percentage of the total money that you are spending on TriWest or 

wherever it is, what percentage of the total spending is going to go 


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26 

to their management fees and which is going to go to actual provider care? Do you understand? 

Mr. MATKOVSKY. Yes I do, sir. So there—— 

Dr. BENISHEK. Can you answer that question? 

Mr. MATKOVSKY. I will. 

Dr. BENISHEK. Or is it not available? 

Mr. MATKOVSKY. First of all, our agreement is with TriWest and 

Health Net. Not with their subcontractors. Second of all, though, 

the structure of the contract is that we pay at a CMS rate to 

TriWest and Health Net and then they will have a rate somewhere 

below that but we are not privy to that. There is an administrative 

fee which is separate to the direct clinical fee, which TriWest and 

Health Net would also bill us. And we expect that their administrative charges would be captured there and not to the detriment of 

their network. There are incentive structures in the contract as 

well. So based on the ability of those organizations to build out 

their networks they get an incentive payment as well. 

Dr. BENISHEK. So there is a separate administration fee? 

Mr. MATKOVSKY. Yes, sir. 

Dr. BENISHEK. And then there is a payment that you are saying 

is based of off Medicare rates to the providers? 

Mr. MATKOVSKY. Yes, sir. 

Dr. BENISHEK. Or that is to Tricare, and they are going to pay 

the providers less than that then? Is that what you said? 

Mr. MATKOVSKY. We are not privy to the information about their 

agreements with their subcontractors. 

Dr. BENISHEK. Well I am just trying to be sure that the system 

actually is able to procure providers. Because if somebody is offering, a very low rate of reimbursement you are not going to get very 

many people to sign up. 

Mr. MATKOVSKY. So far we are not seeing it, be the case across 

the country. That we are actively starting up the sites where we 

are. In VISN 23 it is up and running. There are a number of referrals. We should not be seeing the inability to build out networks 

at this point. 

Dr. BENISHEK. All right. 

Ms. BROWNLEY. Thank you, Mr. Chair. And I will promise you 

I will watch my time. I wanted to go back to the one question that 

I did not think got answered. Maybe it did but I did not hear it 

about the IG’s recommendation for establishing a central program 

resource list for MST related programs? Is that something the VA 

is going to do? Or believes that it is also beneficial? 

Dr. JAIN. I am not sure, Congresswoman Brownley, about the 

question. I am not aware of any central program list in the OIG 

recommendation that is outstanding that I know of. The only one 

that we know of that is outstanding is the whole issue of travel and 

any travel issue. That was the only one that we were aware of. The 

only other thing that does occur to me, so there was one issue in 

OIG, yes, I do recall. And that was the issue that within the VA’s 

intranet there is the availability of different programs and who are 

the MST coordinators. And we have addressed that concern and we 

have updated that list, make sure that the staff is aware that when 

they need to refer a patient to a larger VA, for example, for MST 


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related services, who is the contact person? Who do they need to 

contact? That has been updated and has been addressed. 

Ms. BROWNLEY. Okay. Thank you very much. And I just wanted 

to go to the issue of chronic pain and I am wondering about in testimony before we have had testimony with the Tampa Chronic 

Pain Rehabilitation Program and sort of what are we learning, you 

know, best practices, lessons learned there? 

Dr. PETZEL. Congresswoman Brownley, let me make a couple of 

comments then I am going to turn it over to Dr. Jesse, who was 

at that pain, at that hearing. The VA has developed what I think 

is probably the most robust pain management program for a large 

integrated delivery system in the country. The Tampa inpatient 

program for pain management is an example of the kinds of services that we have to offer. We have taken very seriously the problem with opioid management and pain. I think the physicians in 

this room will remember that 15 years ago it was felt that pain 

was undermanaged, and pain medications were pushed. You need 

to get rid of the pain. That has obviously led, and I am not talking 

about the VA, I am talking about medicine in general, led to a 

problem in this country of the overuse of opioids in managing pain. 

And the VA I think is very seriously addressing that problem. And 

Dr. Jesse? 

Dr. JESSE. Thank you. So there are some very long and detailed 

explanation I can give. I think the VA has a very good story to tell. 

But if coming back specifically to Tampa, Tampa is an inpatient rehabilitation facility that is unlike almost anything else you can get. 

That a patient get this without paying out of pocket is unheard of 

in this country. It is a CARF-accredited program. In 2000, we had 

I think one CARF-accredited program. We now have ten. We have 

14 in process, that accreditation process. Our goal is to ensure that 

every VISN, every network has at least one. And that is part of the 

overall strategy that Dr. Petzel referenced of a stepwise pain management program, beginning with a very comprehensive base in 

primary care including the ability to use therapies other than pharmacologic. You heard about acupuncture, about medication, imaging therapy, behavioral therapy, and escalating, the ability to have 

consultation from pain experts, and escalating up to the higher 

level pain centers where in fact we use a much, we can use much 

more technical programs like spinal stimulation, which was discussed at the last hearing, like nerve blocks, injections, thermal 

nerve ablations. And frankly those are the kind of very intensive 

inpatient rehabilitation programs that Tampa offered. 

Ms. BROWNLEY. So you believe that that is moving really across 

the country in terms of looking at all of the alternative therapies 

that you just suggested? 

Dr. JESSE. Oh yes, absolutely. And so, you know, we have our, 

we have as part of this strategy not just the opioid safety initiative, 

which is key, but it is also the ability to use other strategies to relieve pain rather than just masking them, that is not the right way 

to say that, but rather than just using, you know, pharmacological 

therapy. So for instance as part of the joint program with the Department of Defense there is a program called ATAX, I think is the 

acronym, I do not remember exactly what it stands for, but it is 

to train acupuncturists in what is called battlefield acupuncture, 


VACREP180 with DISTILLER
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auricular acupuncture. Relatively effective at managing pain. The 

goal, we presently have I think just shy of 20 trainers. The goal 

is to have 400 enrolling that program out. Developing that capacity 

is key. And you know, frankly the whole goal of VA as we have discussed in the past is to provide personalized, patient driven care. 

Which really includes a wholesale embracement of I think what the 

industry would call integrative care, integrative medicine. And that 

is, you know, that is part of our fundamental plan of healthcare deliver in VA. 

Ms. BROWNLEY. Thank you. I will yield. 

Dr. BENISHEK. Thank you, Ms. Brownley. Dr. Jesse, I also want 

to ask a couple of questions on that. 

Dr. JESSE. Sure. 

Dr. BENISHEK. On our pain hearing that we had. And I do not 

know, I just want to hear that specifically, you give some, generalized answer here. But specifically since our hearing, what have you 

done to educate the physicians within VA about pain management? 

What has anything changed since our hearing last year? What 

have you done? 

Dr. JESSE. If I may, clearly things have changed because since 

the hearing last year there are 20,000-some fewer veterans on 

opioids. You know, we have been rolling out these initiatives not 

since the hearing but literally since, for four to five years. They 

take time to get in place, they take time to build the infrastructure. 

The opioid safety initiative began to be rolled out prior to that 

hearing and since the hearing there has been a significant acceleration of that. The pilots at Minneapolis, for instance, there has been 

over a 50 percent reduction in the use of opioids. There is a, what 

is called JPEP, it is the Joint Pain Education Program that is done, 

run jointly with the Department of Defense. Because as we have 

discussed in the past one of the key issues, and this came up in 

the past hearing if you remember, we do not want a lapse between 

somebody who is being treated on the military side and coming 

over to the VA. And part of that is to ensure that we actually have 

the same approaches to managing pain across the spectrum of the 

delivery systems, the military system and into the VA system. So 

that program is being rolled out. As I mentioned, the acupuncture 

training program is ramping up. So yes, there are a number of 

issues that are in play that have been much more accelerated since 

that past, that past hearing. 

The Post Deployment Health has calls that average about 400 

people on those monthly calls. We have another set of specific pain 

management calls that have been averaging about 300 in the past 

several months, it is moving up to close to 400. Primary care providers are mostly engaging in these calls. So I think the answer is 

yes. There is concrete and accelerated activity in these areas. 

Dr. BENISHEK. Well I thank you for that answer. I do not mean 

to be overcritical. We just went to the West L.A. Medical Center 

and, met with a couple of their pain specialist providers. And the 

system they had in place there, at least the way they explained it 

to me, it sounded like it was actually pretty effective with, alternative modalities, being incorporated, and having the pain specialist involved in the case at a certain level. And they had a pretty 

good criteria. And so I do not mean to say that everything is bad. 


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But the purpose of today was for me to get a follow up on what, 

is happening. Because I hate to have these hearings where we 

bring up these issues and then, nothing else gets done. I do not 

know the follow up being done. So I truly appreciate you all being 

here today for me to try to get some more information. 

I understand Dr. Wenstrup has a follow up question he would 

like to ask. 

Dr. WENSTRUP. Thank you, Mr. Chairman. Actually sort of on 

that subject, do you know what percentage of the VA hospitals are 

participating in the prescription drug monitoring programs in cooperation with the states? 

Dr. PETZEL. That is a very good question, Congressman. Everybody is querying, that is our providers are asking the state about 

their patients. As near as we know, that is happening across the 

country. The reporting of our activity is an IT issue. We have six 

pilots in places like Kentucky and Tennessee, which have been very 

successful and the process is in place now to roll this out to the 

rest of the country. The limitation is IT, is getting the right people, 

it is complex. You have got different reporting phenomena in each 

state. And you have got 152 medical centers. And getting that stuff 

married up IT-wise is taking us some time. 

Dr. WENSTRUP. Is there anything we can do? 

Dr. PETZEL. Oh dare I say it, IT money. You know. IT is our lifeblood. You know, everything anymore that we do in medicine has 

an IT component to it one way or the other. But I think that the 

money is in place to do this. The people are in place to do it. It 

is just a matter of getting it done. 

Dr. WENSTRUP. Do you have a timeline, do you think? We have 

a pretty big problem in my district with prescription drug abuse. 

It has been cracked down on—— 

Dr. PETZEL. In—— 

Dr. WENSTRUP. In Ohio. 

Dr. PETZEL. In Ohio. 

Dr. WENSTRUP. Yeah. And it has been cracked down a lot. We 

have closed down a lot of the pill mills. That has all been done at 

a local level within the state. But it is still an existing problem. 

Plus, we border other states. Some sometimes we have got it within 

Ohio, but not necessarily in the other states. And having the VA 

information would be helpful as well. 

Dr. PETZEL. It is. And I would like to take for the record the 

question of how long. And we will get back to you quickly about 

exactly what the timeline is. 

Dr. WENSTRUP. Okay, thank you. 

Dr. PETZEL. Just a little bit about that, it is very important and 

from our perspective to know the prescriptions are going on on the 

outside. 

Dr. WENSTRUP. Right. 

Dr. PETZEL. Are people, doctor shopping? Are they using other 

people? And it is important for the states to know what we are 

doing—— 

Dr. WENSTRUP. Right. 

Dr. PETZEL [continuing]. So that they can put that and make 

that information available to the private sector. This is very important. 


VACREP180 with DISTILLER
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Dr. WENSTRUP. It is helpful both ways, there is not doubt about 

it. 

Dr. PETZEL. Yes, absolutely. 

Dr. WENSTRUP. Thank you, and I yield back. 

Dr. BENISHEK. Well I think that concludes the questions that we 

have today. I do have to ask before we adjourn that we do have 

some further written questions we would like to have submitted for 

the record. I suspect that you guys hopefully will get those answers 

to us. There is a lot of lengthy stuff there that I would like to get 

some follow up for but we do not need to have it here today. 

Dr. PETZEL. Yes, sir. 

Dr. BENISHEK. So I appreciate you all being here. I ask unanimous consent that all members have five legislative days to revise 

and extend their remarks and to include extraneous materials. 

Without objection, it is so ordered. And the hearing is now adjourned. 

[Whereupon, at 11:40 a.m., the subcommittee was adjourned.] 


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APPENDIX 

PREPARED STATEMENT OF HON. DAN BENISHEK M.D., CHAIRMAN

Good morning and thank you for joining us for today’s oversight hearing, ‘‘VA Accountability: Actions Taken in Response to Subcommittee Oversight.’’ 

Almost one year ago today—during my first hearing as Chairman of the Subcommittee on Health—we met to discuss the persistent lack of productivity and 

staffing standards for specialty care services at Department of Veterans Affairs (VA) 

medical facilities. 

We learned that VA had yet to implement such standards despite more than thirty years of reports and recommendations directing the Department to do so. 

I was so alarmed by VA’s decades-long lack of action that I quickly introduced 

H.R. 2072, the Demanding Accountability for Veterans Act. 

H.R. 2072 would: 

• Require VA to ensure that IG recommendations concerning a public health 

or patient safety issue were addressed; 

• identify those within VA medical facilities who are responsible for implementing needed changes; and, 

• prohibit VA from awarding a bonus or performance award to any employee 

who does not fully address a recommendation under his or her purview. 

The goal of this legislation is to create a culture of accountability within VA—a 

culture where problems are identified and immediately corrected and leaders are 

held responsible for their actions. 

Were H.R. 2072 in place thirty years ago, VA would have been required long before now to implement productivity and staffing standards for all specialty care 

services and who knows how the health and well-being of the veterans seeking care 

through VA would have improved as a result. 

I wish I could say that first hearing was the only time that we have seen evidence 

of a lack of timely action taken by VA in response to serious problems. 

Unfortunately, that is not true. 

Since the conclusion of that hearing, we have held other hearings and roundtables 

on topics ranging from the care provided to veterans with chronic pain and who 

have experienced military sexual trauma to concerns regarding Department-wide 

procurement reform and third-party collections. 

At each of these oversight forums, we heard example after example of VA failing 

to act swiftly to address important issues or respond to the Subcommittee’s requests 

for information in a timely manner. 

I am a surgeon by trade. 

When a serious problem is identified, my instinct is to act without delay to cut 

out what needs cutting out and fix what needs fixing. 

And, while I understand that large-scale changes often happen slowly—especially 

where large government bureaucracies like VA are concerned—I think we can all 

agree that our veterans deserve more than what we have seen in the last year. 

I am hopeful that H.R. 2072 will be heard on the House floor in the coming weeks. 

However, I am not content to wait for what can oftentimes be a lengthy legislative 

process to ensure that VA is on track to address the many issues the Subcommittee 

identified through last year’s oversight efforts. 

During today’s hearing we will: 

• Assess the progress, if any, that VA has made in response to the Subcommittee’s hearings and roundtables; 

• Determine whether appropriate steps have been taken to ensure accountability when and where deficiencies in care have been highlighted; and, 

• Identify what further actions may be necessary to improve the care and services provided to our veterans. 

Though the topics we will address today are wide-ranging, they are undoubtedly 

interconnected. 

If we do not ensure that the Department is on track to implement appropriate 

productivity and staffing standards, then we cannot be sure that we have the right 

staff in place to care for veterans experiencing chronic pain. 

Similarly, if we do not ensure that VA is taking all necessary actions to improve 

the collection, where appropriate, of third-party revenue, then we cannot be sure 

that we are collecting every available dollar that could then, in turn, be used to improve the care and services provided to veteran survivors of military sexual trauma. 

Last week, I had the privilege of conducting an oversight visit to the West LA 

VA Medical Center. 


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During my conversations with the clinicians and support staff there, each of the 

issues we will discuss today were brought up by the providers when I asked them 

what needed to be improved in order to make it easier for them to care for our veterans. 

I cannot state enough how critical it is for VA to take responsibility for gaps in 

care and, more importantly, take immediate and definitive steps to address them. 

Unfortunately, I have seen little concrete evidence in the last year that the Department is doing either. 

Concurring with IG and GAO reports is simply not enough. 

Sending out guidelines without accountability in not enough. 

I sincerely hope that today’s conversation will change my mind. 

f 

PREPARED STATEMENT OF JULIA BROWNLEY, RANKING MEMBER

Good morning. Today’s hearing is intended to follow up on various oversight hearings and roundtables held during the first session of the 113th Congress and to assess the progress that the Department has made in addressing the issues. 

The Subcommittee will also determine whether appropriate steps have been taken 

by VA to ensure accountability, and identify what further actions may be necessary 

in response to Subcommittee oversight. 

Last session, this Subcommittee held oversight hearings on physician staffing 

standards, care and treatment for military sexual trauma survivors, and VA’s overuse of prescription painkillers to treat veterans with chronic pain. 

In addition to the oversight hearings, two roundtables were held, one focusing on 

procurement reform and access to care and one on billing and collecting from thirdparty health insurance companies for nonservice-connected care. 

There were many issues raised during these hearings and roundtables. Issues 

such as developing a plan to establish productivity standards for all specialty care 

services within three years, decreasing the amount of time it takes to procure large 

medical equipment through the National Acquisition Center, assessing the Department’s programs for veterans who have experienced military sexual trauma, and ensuring the effective use of opioid therapy for patients with chronic pain. 

Mr. Chairman, these are but a few of the concerns that were brought up during 

testimony and conversations we had with the witnesses and participants during the 

forums. 

While we have a lot of ground to cover today, I am especially interested in hearing 

from the VA on improvements made in the MST program and in procurement reform. 

At the MST hearing held last session, we heard first hand the experiences of veterans who have found the system unfriendly and intimidating. 

According to the VA, fiscal year 2013 saw an increase of 9.3 percent in rates of 

engagement of MST-related care at VHA. Additionally, VA reports an increase of 

14.6 percent in MST-related visits in fiscal year 2013. I would like to hear from VA 

how they are addressing this increase. 

I am sure we all agree that it is critical that Congress do all that we can to make 

it easier for victims of MST to access needed benefits and services, and receive 

treatment. 

Compassion and care are a significant part of healing those that have been sexually assaulted. 

Turning now to procurement reform, Mr. Chairman, last session we held a roundtable and during that roundtable discussion, we heard about the long delays, some 

for up to two years, in the delivery of medical equipment. 

While I understand that VA is streamlining the procurement process to decrease 

the amount of time it takes to procure large medical equipment through the National Acquisition Center, I do not feel confident that much progress has been made 

in that area. 

Stakeholders continue to report increased difficulties accessing needed prosthetic 

equipment through VA and significant delays in contract awards at the National Acquisition Center. 

I find this very frustrating and unnecessary. I hope VA has good news on this 

front today. 

Mr. Chairman, thank you for holding this hearing today and I want to thank everyone in attendance. There is obvious concern for veterans and VA’s ability to meet 

their health care needs. 

Thank you, Mr. Chairman and I yield back the balance of my time. 


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PREPARED STATEMENT OF ROBERT PETZEL, M.D. 

Good morning, Chairman Benishek, Ranking Member Brownley, and members of 

the Committee. Thank you for the opportunity to discuss the progress made regarding the Veterans Health Administration’s (VHA) physician staffing and productivity 

standards, treatment for Veterans who experienced military sexual trauma, pain 

management programs, and procurement reform. I am accompanied today by Dr. 

Robert Jesse, Principal Deputy Under Secretary for Health, Dr. Madhulika Agarwal, 

Deputy Under Secretary for Health for Policy and Services, Dr. Rajiv Jain, Assistant 

Deputy Under Secretary for Health for Patient Care Services, and Mr. Philip 

Matkovsky, Assistant Deputy Under Secretary for Health for Administrative Operations. 

The Department of Veterans Affairs (VA) is committed to providing the highest 

quality care, which our Veterans have earned and deserve. VA operates the largest 

integrated health care delivery system in the country, with over 1,700 sites of care. 

It is important to acknowledge that each year, over 200,000 VHA leaders and health 

care employees provide exceptional care to approximately 6.3 million Veterans. The 

high quality health care VA provides is consistently recognized by The Joint Commission and other internal and external reviews. 

I want to address the issue of accountability. The Veterans Health Administration 

is the largest integrated health care system in the country, providing 85 million 

total health care appointments last year and 25 million consultations at more than 

1,700 VA health care sites. Allegations of misconduct by employees are taken seriously. When we learn of credible allegations of misconduct, VA addresses them immediately. 

When incidents occur, we identify, mitigate and prevent additional risks. Prompt 

reviews prevent similar events in the future and hold those responsible accountable. 

If employee misconduct or failure to meet performance standards is identified, VA 

takes the appropriate action. 

I would point out that VA appreciates and values the role that Congress, this 

Committee, VA’s Office of the Inspector General (OIG), the Office of Special Counsel, and the Government Accountability Office have played in identifying areas 

where the VHA can improve. VA utilizes their insights when forming policy and 

taking action to strengthen our healthcare delivery programs. 

CARE AND TREATMENT AVAILABLE TO SURVIVORS OF MILITARY SEXUAL TRAUMA

Effectively treating Veterans who experienced military sexual trauma (MST) continues to be a top VA priority. We are committed to ensuring that appropriate MST 

services are available to meet the treatment needs of both men and women Veterans. Rates of engagement in care and the amount of care provided have increased 

every year that VA has monitored MST-related treatment. In fiscal year (FY) 2013, 

93,439 Veterans received MST-related care at VHA. This is an increase of 9.3 percent (from 85,474) from FY 2012. These Veterans had a total of 1,027,810 MST-related visits in FY 2013, which represents an increase of 14.6 percent (from 896,947) 

from FY 2012. 

At last year’s hearing on care and treatment available to survivors of MST, we 

discussed VA initiatives to provide counseling and care to Veterans who experienced 

MST; monitor MST-related screening and treatment; provide VA staff with training; 

and inform Veterans about available services. Since that hearing, VHA has made 

significant improvements in these areas. VA has implemented improvements in 

MST care to include enhanced screening, expanded telemental health services, and 

expanded guidance. 

As discussed during the hearing, VHA has a universal screening program for 

MST. A Clinical Reminder in the electronic medical record alerts providers of the 

need to screen the Veteran, provides language to use in asking the Veteran about 

MST, and documents the Veteran’s response to the screen. Because a revision of the 

MST Clinical Reminder will be rolled out by the end of FY 2014, VHA will implement several changes including changing the Clinical Reminder language to make 

the questions asked more readily understandable to Veterans. Also, an explicit option to ‘‘decline’’ has been added, to allow Veterans to choose when and with whom 

they would prefer to disclose their experience. Veterans who ‘‘decline’’ are automatically re-screened again in a year. Although the intent of these changes is to facilitate disclosure, the revised Reminder language also capitalizes on screening as an 

opportunity to provide all Veterans with information about VHA’s specialized MST 

services, regardless of whether or not they disclose having experienced MST. Veterans who express interest in MST-related treatment will have streamlined access 

to care via an option in the Reminder itself to initiate a referral for services. 


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In conjunction with the rollout of the revised Clinical Reminder, VHA has engaged in efforts to provide staff with additional training on how to screen and respond sensitively to disclosures of MST. National educational resources have also 

shifted to clarify the importance of creating multiple opportunities for disclosure of 

experiences for MST—for example, re-screening all Veterans who are seen in clinics 

for posttraumatic stress disorder (PTSD) or other specialty services. 

The addition of the referral question to the Clinical Reminder will allow for increased accountability with respect to the MST-related treatment provided by VHA. 

First, it will provide national monitoring data that will allow VHA to track whether 

Veterans who request MST-related mental health services are able to access those 

services. Second, it will allow VHA to establish benchmarks for what percent of Veterans (on average) might be expected to access MST-related care after screening 

positive. Veterans who screen positive for MST will vary in their need and interest 

in MST-related treatment through VHA; without some indication of what percent 

of Veterans are interested in treatment, it is currently difficult to know the extent 

to which VA is reaching the subset of Veterans who actually need care. 

Given the increases in MST-related treatment mentioned earlier, it is important 

to ensure that facilities have adequate capacity to meet the demand for care. Analyses conducted by VHA’s national MST Support Team established a minimum staffing benchmark of 0.2 full time equivalent employees per 100 Veterans who screen 

positive for MST. Annual monitoring of all VHA facilities using this benchmark 

demonstrated a positive impact on the availability of services. These analyses, in 

conjunction with the new referral question associated with the Clinical Reminder, 

will assist VHA in assessing continued progress towards the goal of ensuring that 

all Veterans who would benefit from MST-related care are able to readily access 

that care. 

During the previous hearing on MST, we discussed the geographic challenges 

some Veterans face when seeking to access care. VHA is providing services via information and telecommunication technologies that give Veterans more options and 

have improved access to care. Telemental health approaches can be used to treat 

most every mental health condition and deliver all Evidence-based Psychotherapies 

(EBP). As part of its strong commitment toward providing high quality mental 

health care, VHA has nationally disseminated and implemented specific EBPs for 

PTSD and other mental and behavioral health conditions. Because PTSD, depression and anxiety are commonly associated with MST, these national initiatives are 

important means of expanding MST survivors’ access to treatments. Furthermore, 

several of these treatments were originally developed to treat sexual assault survivors and have a particularly strong research base with this population. 

Veterans who experienced MST can receive EBPs at every VA medical center and 

increasingly via telehealth. VHA’s work in this area is supported by recent research, 

including research conducted within VHA that has shown these therapies to be effective and well-accepted by patients when delivered. VA administrative data indicates that from FY 2011 to FY 2013 psychotherapy telemental health encounters 

with Veterans with primary diagnosis with PTSD has increased more than 3-fold 

and during the same time frame, the number of unique Veterans with primary diagnosis of PTSD receiving psychotherapy via telemental health has more than doubled. This is due in part to national VHA efforts to expand the use of telehealth 

to providing care, particularly to Veterans with PTSD. 

In September, an Information Bulletin was distributed to Veterans Integrated 

Service Network (VISN) leadership that provided guidance on the importance of protected time for the MST Coordinator, ensuring facilities have sufficient capacity to 

provide MST-related care, and clarification that non-VA (fee basis) care can, and 

should, be provided when there will be a delay in the facility’s ability to meet a Veteran’s treatment needs, or if it is otherwise clinically indicated for the MST-related 

care to be delivered at a non-VA facility. The Information Bulletin also underscored 

the need to ensure adequate services are available to meet the needs of male Veterans who experienced MST and that these services are provided in a manner that 

recognizes some of the unique challenges men may face in accessing care and in 

their recovery more generally. The revised MST Clinical Reminder will include a 

mental health services referral question, which will streamline access to care for 

Veterans who express interest in MST-related treatment. In recognition of this, at 

a national level, MST is clearly defined as an issue of concern for both men and 

women, in that it has been under the administrative oversight of the national Mental Health Services program office since 2006. 

In 2013, VHA concurred with the Office of the Inspector General’s recommendation to review existing VHA policy pertaining to authorization of travel for Veterans 

seeking MST-related treatment at specialized inpatient/residential programs outside 

of the facilities where they are enrolled. VHA agreed to establish a workgroup to 


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review the issues and provide recommendations to the Under Secretary for Health. 

After reviewing current policies, the workgroup confirmed that currently, MST status does not in and of itself qualify Veterans for reimbursement of travel expenses 

(called Beneficiary Travel) and drafted an initial proposal discussing potential options for addressing this issue. The work group has been directed to conduct further 

analysis and reach consensus on a recommendation. 

Department-Wide Acquisition Reform 

The Subcommittee also hosted a number of roundtables to examine the impact 

Department-wide acquisition reform has had on access and quality of care for Veteran patients and opportunities to improve patient care in addition to the authority 

to bill and collect from third party health insurance companies. We discussed the 

processes used to provide non-VA care for Veterans and how billing was conducted 

following the care being delivered. We also discussed VA standards for claims payment and performance metrics used to track VA results as well as the consolidation 

of billing and the improvements and efficiencies recognized from the changes. 

Since the roundtable discussions, the Department has expanded its use of authorities to acquire care from community health care providers. In January 2014, we successfully launched delivery of healthcare through Patient Centered Community Care 

(PC3) contracts, beginning a phased deployment across the VA health care system. 

This new program employs nation-wide contracts to improve Veterans’ access to 

quality health care. These contracts also standardize our referral, authorization and 

payment processes. Our phased deployment will achieve delivery of health care 

through PC3 across all VISNs in April of 2014. 

VA completed its consolidation of billing through the Consolidated Patient Account Centers (CPAC) in September 2012. This effort was completed ahead of schedule, and has improved the reliability and performance of our billing and collection 

processes. Since our roundtable discussions we have conducted requests for information through the Federal government procurement system to identify commercial 

best practices for automation of health care billing systems. This approach was a 

direct result to the discussions conducted at the roundtable, and it allows our VA 

team to collect competitive information from numerous firms. We are now processing responses and assessing how best to further develop a solicitation to improve 

our automation of hospital billing. 

Additionally, we met with the Health Subcommittee regarding claims payment 

timeliness. We have established a nation-wide effort to improve the timeliness of all 

claims VA pays to providers who provide authorized care to Veterans. We are currently working with our legacy systems and have increased oversight of our claims 

payment processes. We have partnered with our Department colleagues to develop 

a fully automated and commercial claims payment system that will enable improved 

and sustainable performance in our payment processes. This system is in field-testing in one of our networks and will complete development by the end of this calendar year, with a subsequent national roll-out and training for all our claims payment staff by the end of FY 2015. 

We have welcomed the involvement from this Subcommittee during our 

roundtables, which has informed the continued improvements in our administrative 

processes. 

Physician Staffing and Productivity Standards 

At last year’s hearing, we discussed how VHA was addressing productivity and 

staffing beginning with Primary Care Services followed by Radiology and Mental 

Health. We also discussed the complexities associated with measuring productivity 

in a health care setting. VHA reported in March 2013 that more than 54 percent 

of its physician workforce had standards in place to measure their productivity and 

efficiency. 

Today, I am pleased to report that we are on target to deliver productivity and 

staffing standards for all VHA physicians by the end of FY 2014. In October 2013, 

VHA briefed the OIG on its progress on developing and implementing specialty physician productivity and staffing standards. Based on VHA’s briefing, the OIG closed 

out its ‘‘Audit of Physician Staffing Levels for Specialty Care Services,’’ OIG report 

11–01827–36, in November of 2013. The work continues and we will not be finished 

until all physician specialty productivity and staffing standards are complete and 

ready access to high quality, efficient specialty care is available to our Nations Veterans 

Today, I’d like to share with you some of the details of what we have accomplished and assure this Subcommittee of VHA’s commitment to the results-oriented 

approach we have taken in accomplishing the implementation of physician productivity and staffing standards. VHA has adopted an activity-based productivity and 


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1 According to a 2010 Institute of Medicine estimate, the rate of chronic pain in the general 

population is approximately 32 percent. 

staffing model for specialty physicians. Utilizing an industry accepted Relative 

Value Unit (RVU)-based model, specialty physician productivity standards have 

been developed and implemented. In FY 2013, productivity standards for six specialties (dermatology, neurology, gastroenterology, orthopedics, urology, and ophthalmology) were developed, piloted in four VISNs (VISNs (7, 12, 19 & 22)) and then 

implemented VHA-wide in FY 2013. All VISNs and medical centers were informed 

of the new productivity standards for the six physician specialties listed above on 

July 26, 2013. The standards were implemented VHA-wide on September 30, 2013. 

By the end of March 2014, VHA will have productivity and staffing standards in 

place for 25 different specialties representing more than 81 percent of its total physician workforce. 

A critical component of the productivity and staffing standard implementation is 

the Specialty Productivity-Access Report & Quadrant (SPARQ) tool that provides an 

algorithm for the effective management of VHA’s specialty physician practices. This 

tool is designed to assess VHA specialty physician practice business strategies and 

drive performance improvement in Veteran access to specialty care. This tool was 

recognized by our OIG colleagues as one of the most important managerial tools developed in support of physician productivity and staffing standards and its ability 

to go beyond standard implementation to ultimately drive system performance. 

The SPARQ tool includes important measures, such as support staff ratios for 

VHA specialty physicians so as to maximize physician efficiency. The SPARQ tool 

measures the care team, including advanced practice providers such as Nurse Practitioners, Physician Assistants, and Clinical Nurse Specialists, and their RVU contribution. The SPARQ tool also measures specialty physician value in the form of 

‘compensation per RVU’ so as to demonstrate VHA’s ability to be good stewards of 

public health care resources. Additional views for local medical center and VISN 

leadership have been added to permit a view of all specialties so that local leaders 

can make informed decisions about specialty care resources and be accountable for 

these decisions. 

VHA has also undertaken a comprehensive education and communication plan 

about the specialty physician productivity and staffing standards. VHA has held national calls to actively engage its specialty physician workforce. VHA specialty physicians are committed to demonstrating and improving specialty productivity and 

access. VHA has also held national calls with its medical center leadership in an 

effort to clearly communicate the expectations of full implementation of specialty 

physician productivity and staffing standards. All medical centers have been provided with access to a variety of tools that permit productivity and staffing measurement at the individual physician and specialty practice level. Our national and local 

specialty leaders have been trained on the business strategies and tools available 

to assist them in managing their specialty practices with the goal of ready access 

to quality specialty care for our Veterans. 

VA’s Pain Management Programs and the Use of Medications to Treat Veterans 

At last year’s hearing, we discussed how VA is providing comprehensive and patient-centered pain management services to improve the health of Veterans. We also 

highlighted VA’s current pain management strategies, the prevalence and use of 

opioid therapy to manage chronic pain in Veterans who are potentially at increased 

risk for a medication-related adverse event such as someone taking a high dose of 

an opioid at the same time as taking a benzodiazepine medication, the challenges 

of prescription drug diversion and abuse among Veterans, and the actions VA is taking to improve the management of chronic pain. 

Today, we are providing an update on our progress and the on-going challenges 

that we are working on in order to provide the best care to our deserving Veterans 

when it comes to managing their pain. This includes the integration of both medications and non-pharmacologic evidence-based strategies. 

Veterans enrolled in VA’s health care system suffer from higher rates of chronic 

pain than the general population.1 Almost 60 percent of Veterans returning from 

the Middle East and more than 50 percent of Veterans in the entire VA health care 

system experience some form of chronic pain. Many have survived severe battlefield 

injuries, resulting in life-long severe pain related to damage to their musculoskeletal 

system, as well as permanent nerve damage, which can impact their emotional 

health and brain structures. Many have also incurred head injuries, collectively referred to as traumatic brain injuries (TBI), which can compound psychological injuries such as PTSD. The extent and complexity of these multiple conditions can make 


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effective pain management difficult and increase the risk for complications, due to 

both over-and under-treatment, including overdose and suicide. 

In 2011, the Institute of Medicine (IOM) issued their report describing general 

deficits in the training of U.S. health care professionals in pain management. VA’s 

health care system had identified and broadly responded to these deficits starting 

in the late 1990s through policy, education and training, clinical monitoring, and the 

expansion of clinical resources and programs. For instance, VA recognized that in 

the management of pain, and for mental health problems such as PTSD, that can 

accompany combat injury related pain, there may be value to non-medication treatment approaches, including evidence-based psychotherapy and complementary and 

alternative medicine (CAM) approaches such as meditation, animal-assisted therapies and acupuncture. Several of these approaches are in active use and are under 

ongoing evaluation. 

VA recently developed and implemented an Opioid Safety Initiative program to 

better ensure opioid pain medications are used safely, effectively and judiciously. 

The basis for this is to make visible the totality of opioid use at all levels, patient, 

provider and facility, in order to identify high-risk situations. The Opioid Safety Initiative includes key clinical indicators such as the number of unique pharmacy patients dispensed an opioid, unique patients on long-term opioids who receive a urine 

drug screen, the number of patients receiving an opioid and a benzodiazepine (which 

puts them at a higher risk of adverse events) and the average dosage per day of 

opioids such as hydromorphone, methadone, morphine, oxycodone, and 

oxymorphone. Patients at risk for adverse events from use of opioids are identified 

through the use of administrative and clinical databases using pre-determined parameters based on published evidence and expert opinion. Several aspects of the 

Opioid Safety Initiative were underway at the time of the October 10, 2013, hearing 

and have begun to bear positive results: 

• Despite overall growth in the number of Veterans who were dispensed any 

medication from a VA pharmacy, between the quarter beginning in July 2012 

compared to quarter ending in December 2013, 33,142 fewer Veterans received 

any opioid prescription (including short and long term use) from VA. 

• Performing urine drug screens is a useful tool to assist in the clinical management of patients receiving long-term opioid therapy. Between the quarter beginning in July 2012 compared to quarter ending in December 2013, the number 

of patients on long term opioid therapy who have had at least one urine drug 

screen increased by 27,783, while the total number of patients on long term 

opioids decreased by 13,859. 

• Whenever clinically feasible, the concomitant use of opioid and 

benzodiazepine medications should be avoided. Between the quarter beginning 

in July 2012 compared to quarter ending in December 2013, 10,664 fewer patients were receiving these drugs at the same time. 

• Lastly, the average dose of selected opioids has begun to decline slightly in 

VA, demonstrating that prescribing and consumption behaviors are changing. 

These facts signal an important downward trend in VA’s prescribing of opioids. 

VA expects this trend to continue as it renews its efforts to promote safe and effective pharmacologic and non-pharmacologic pain management therapies. Very effective programs yielding significant results have been identified, and are being studied as strong practice leaders. 

At the Tampa VA medical center, a safety-focused pain treatment program has 

been in place since 1988. The goal of the program is to replace the use of opioids 

for pain management with non-pharmacologic treatments such as behavior therapy, 

physical therapy, occupational therapy and/or kinesiotherapy. Tampa also has a 

long-standing process of identifying and conducting clinical reviews of Veterans who 

have received high morphine equivalent doses. At the Columbus, Ohio VA Outpatient Clinic, a Veteran-centered approach on opioid safety is focused on minimizing short acting opioids. This program has resulted in fewer Veterans on opioids 

with an 80 percent decrease in short acting opioid doses dispensed. 

Current VA Pain Management Strategies 

Many Veterans require a combination of strategies for the effective management 

of pain, including treatment with opioid analgesics, which are known to be effective 

for at least partially relieving pain caused by many different medical conditions and 

injuries. VA treatment involves 1) interrupting or moderating the pain signal from 

peripheral disease/damage (e.g., medications/injections, transcutaneous electrical 

nerve stimulation (TENS), acupuncture, and stimulation.); 2) supporting structures 

(e.g., spine) to reduce activation of pain signals (physical therapy and exercise to 


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build strength and flexibility and help control weight); and 3) help the Veteran cope 

with pain and learn better self-management strategies (behavioral therapies). 

In 2010, the Department of Defense (DoD) and VA jointly published evidencebased Clinical Practice Guidelines (CPG) for the use of chronic opioid therapy in 

chronic pain available on the internet. Guidelines reserve the use of chronic opioids 

for patients with moderate to severe pain who have not responded to, or responded 

only partially to, clinically indicated evidence-based pain management strategies of 

lower risk, and who also may benefit from a trial of opioids. A toolkit has also been 

published and widely distributed to assist clinicians in using the Guidelines: 

(https://www/qmo.amedd.army.mil and http://www.healthquality.va.gov). VA has 

also developed and disseminated a patient education resource, entitled ‘‘Taking 

Opioids Responsibly’’, to increase Veterans’ awareness of the risks and benefits of 

opioid treatment. More recently, the DoD-VA Pain Management Work Group 

(PMWG) of the VA-DoD Health Executive Council (HEC) has built upon the past 

work begun with the 2010 CPG and meets monthly to evaluate progress and improve effectiveness of projects focused upon the VA–DoD mission to improve pain 

management. These include two projects funded in 2013 and well underway: Joint 

Pain Education and Training Project (JPEP)’’, and ‘‘Tiered Acupuncture Training 

Across Clinical Settings (ATACS).’’ 

To support a system-wide approach, VA disseminated guidance and tools to providers to communicate long term opioid therapy expectations. Among the tools and 

guidance are: 

a. VA National Pain Management Strategy—VA has established pain management as a national priority. The objective of the strategy is a comprehensive, multicultural, integrated system-wide approach to pain management that reduces pain 

and suffering and improves quality of life for Veterans experiencing acute and 

chronic pain. The strategy incorporates care by pain medicine, behavioral health, 

physical medicine and rehabilitation and other specialty providers to manage complex patients. 

b. VHA Pain Management Directive—VA’s Pain Management Directive defines 

and describes policy expectations and responsibilities for the overall National Pain 

Management Strategy and Stepped Care pain model. 

In coordination with DoD, a multi-modality, team-based, stepped care model is 

being implemented throughout VA. VA and DoD have developed patient and provider educational materials and two Joint Incentive Fund sponsored initiatives are 

underway. 

The Acupuncture Training Across Clinical Settings Project will create access to 

acupuncture for Veterans and Servicemembers in all clinical settings throughout VA 

and DoD. 

Forty-eight states have implemented Prescription Drug Monitoring Programs 

(PDMP) as a means to improve the quality of care and prevent the diversion of controlled substances. Two additional states and the District of Columbia have enacted 

legislation to develop a PDMP or have legislation pending. VA published an Interim 

Final Rule to allow participation in these programs and is successfully transmitting 

data from six pilot sites to state PDMPs. The remaining VA facilities are scheduled 

to begin transmitting data by the end of FY 2014. 

Non-pharmacologic Approaches to Treatment of Veterans’ Mental Health 

Problems and Pain Management 

The treatment of PTSD in VA follows the evidence-based recommendations of the 

Joint VA/DoD Clinical Practice Guideline for PTSD, most recently published in 2010 

and accessible on the Internet at http://www.healthquality.va.gov/ptsd/. The firstline treatments for PTSD are evidence-based trauma focused psychotherapies such 

as Cognitive Processing Therapy (CPT) or Prolonged Exposure (PE) that have the 

highest level of evidence (Level A) indicating ‘‘a strong recommendation that the 

intervention is always indicated and acceptable.’’ 

In terms of medications, the Guidelines strongly recommend (Level A) selective 

serotonin reuptake inhibitors or serotonin norepinephrine reuptake inhibitors. To 

date, VA has provided training in Cognitive Processing Therapy and/or Prolonged 

Exposure to more than 6,000 VA mental health staff. All VA medical centers provide 

at least one of these therapies, as required in VHA Handbook 1160.01, Uniform 

Mental Health Services in VA Medical Centers and Clinics. According to a 2011 VA 

survey, 89 percent of VA facilities offered CAM treatments, an increase from 84 percent in 2002. The most common types of CAM provided are meditation (72 percent 

of VA hospitals); Stress Management/Relaxation Therapy (66 percent); and Guided 

Imagery (58 percent); acupuncture (41 percent), and yoga (44 percent). The most 

common uses of CAM are for stress management, anxiety disorder, PTSD, depression, back pain, and wellness-promotion. 


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The Acupuncture Training Across Clinical Settings Project is now in development 

to ensure, through standardized training of medical and battlefield acupuncturists, 

that all Veterans and Servicemembers in all clinical settings throughout VA and 

DoD have access to appropriate levels of acupuncture. VA has submitted a request 

for job classification to OPM for the hiring of certified acupuncturists. 

VA and DoD combined VA’s Health and Information Group survey of CAM modalities with the RAND survey of DoD Innovative Mental Health Programs as the 

foundation for a joint registry that will provide a record of innovative treatment programs. The combined list now includes over 700 programs and is a substantial initial step toward characterizing and tracking innovative treatment modalities. 

Conclusion 

As stated earlier, the Department of Veterans Affairs is committed to providing 

the highest quality care, which our Veterans have earned and deserve. Progress has 

been made regarding physician staffing and productivity standards, treatment for 

Veterans who experienced military sexual trauma, pain management programs, and 

procurement reform, and we will continue to seek improvement as we deliver high 

quality health care. 

We will continue to identify, mitigate, and prevent vulnerabilities within our 

health care system, wherever we find them, and we will continue to ensure accountability and develop a culture in which accountability principles are clearly stated. 

And when adverse events do occur, we will identify them, learn from them, improve 

our systems, and do all we can to prevent these incidents from happening again. 

Mr. Chairman, this concludes my testimony. I appreciate the Subcommittee’s continued interest in the health and welfare of America’s Veterans. At this time, my 

colleagues and I are prepared to answer your questions. 

f 

March 20, 2014 

The Honorable Robert A. Petzel, M.D. 

Under Secretary for Health 

U.S. Department of Veterans Affairs 

810 Vermont Avenue, NW 

Washington, DC 20420 

Dear Dr. Petzel: 

Thank you for testifying at the February 26, 2014, Subcommittee on Health oversight hearing entitled, ‘‘VA Accountability: Assessing Actions Taken in Response to 

Subcommittee Oversight.’’ 

As a follow-up to that hearing, I request that you respond to the attached questions and provide the requested materials in-full by no later than close of business 

on Friday, April 25, 2014. 

If you have any questions, please contact Christine Hill, Staff Director for the 

Subcommittee on Health, at Christine.Hill@mail.house.gov or by calling (202) 225– 

9154. 

Your timely response to this matter and your commitment to our nation’s veterans are both very much appreciated. 

Sincerely, 

DAN BENISHEK M.D. 

Chairman 

Questions for the Record From Chairman Dan Benishek M.D., 

1. During the hearing, you stated that, ‘‘ . . . last year, VA removed 3,000 employees—approximately one percent of its workforce.’’ Please provide the location, 

position, salary grade, and reason for dismissal for each of the 3,000 employees that 

the Department removed last year. Please also provide the number of employees 

that were resigned on threat of discipline last year. 

2. During questioning by Representative Wenstrup, you stated that the Department has conducted ‘‘several’’ studies comparing the cost of providing a given medical service through VA to the cost of providing the same service through either 

Medicare or the private sector. Please provide an electronic copy of such studies. 

3. Please provide a copy of the Information Bulletin that was distributed to Veterans Integrated Service Network (VISN) leadership in September 2013 regarding 

Military Sexual Trauma (MST) Coordinators and describe how the Department intends to measure and track the implementation, utilization, and effect of the Information Bulletin. 


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4. Please describe how the Department intends to measure and track the implementation, utilization, and effect of the revised MST clinical reminder screening 

process. Is the Department on track to roll out the revised screening process by the 

end of fiscal year 2014? 

5. Please provide information regarding the number and location of any and all 

inpatient facilities or programs that exist specifically for the treatment of MST and 

whether such facilities or programs treat male veterans, female veterans, or both. 

6. Please describe the actions the Department is taking to expand access to care 

for male veterans who have experienced MST. 

7. Please provide a copy of the ‘‘national educational resources’’ referenced in the 

Department’s written statement that have been ‘‘shifted to clarify the importance 

of creasing multiple opportunities for disclosure [of MST.’’ What impact are these 

resources expected to have and how will such impact be tracked and measured? 

8. Please provide information regarding the pilot program that Mr. Matkovsky, 

VA’s Assistant Deputy Under Secretary for Health for Administrative Operations, 

stated the Department was undergoing in VISN 15 and VISN 23 to test an alternate 

procurement structure for certain high-cost medical equipment. Please include information regarding how the Department intends to measure the outcome of the pilot 

program. 

9. Is the Department still on track to complete the approximately 909 outstanding 

delivery orders from 2012 by the end of April 2014? If now, why not and when will 

the outstanding delivery order be filled? 

10. Please describe how the Department intends to, ‘‘ . . . look at the consolidation 

process and change that as well.’’ What changes are planned for VA’s current consolidation process and what is the Department’s timeline for full implementation of 

the planned changes? 

11. Please describe the actions that have been taken in the last year to respond 

to veteran and stakeholder concerns regarding the negative impact of changes to 

VA’s prosthetic procurement process. 

12. Please list the ‘‘incentive structures’’ in the Patient Centered Community Care 

(PC3) program that Mr. Matkovsky mentioned in response to questions regarding 

PC3 reimbursement rates. 

13. What impact does the Department estimate full implementation of PC3 will 

have on VA’s third-party collections? 

14. Please provide an update on the request for information (RFI) that the Department released to ‘‘ . . . identify commercial best practices for automation of 

health care billing systems . . . ’’ What response has the Department received to the 

RFI and how and when does the Department intend to incorporate those best practices into VA’s third-party collections processes? 

15. Please list and briefly describe each of the ‘‘many tools’’ that Dr. Agarwal, 

VA’s Deputy Under Secretary for Health for Policy and Services, testified had been 

developed to, ‘‘ . . . assist the local facilities in managing specialty [care] resources 

appropriately.’’ Please also describe how the Department intends to track the implementation and utilization of these tools and measure the impact they have on veteran access to specialty care services. 

16. Please provide information regarding the ‘‘comprehensive education and communication plan’’ that is currently underway regarding specialty physician productivity and staffing standards. 

17. VHA Directive 2009–053, which provides pain management policy and implementation procedures, is scheduled to expire on October 31, 2014. Please describe 

the Department’s efforts to-date to prepare to update and reissue this directive and 

list any and all proposed policy or implementation changes that have been proposed. 

18. Please describe the role of the Opioid Safety Initiative within VA’s existing 

pain management programs and provide information regarding how the Department 

intends to measure and track the Initiative’s implementation, utilization, and impact. 

19. Please describe that actions, if any, that the Department has taken to ensure 

that pain management points of contact (POCs) within VA medical facilities regularly communicate with pain management specialists, as appropriate, about veteran 

patients experiencing acute or chronic pain. Please include any and all guidance 

that has been sent to the field regarding the referral process from pain management 

POCs to pain management specialists. 

20. During the Subcommittee’s October 10, 2013, oversight hearing entitled, ‘‘Between Peril and Promise: Facing the Dangers of VA’s Skyrocketing Use of Prescription Painkillers to Treat Veterans,’’ a VA witness testified about a VA-wide best 

practice in pain management called the ‘‘Chronic Pain Rehabilitation Program.’’ 

Please describe what efforts, if any, VA has taken to implement related or similar 

programs in other VA medical centers and clinics. 


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21. Please describe the six ongoing pilot programs that are in place to test the 

Department’s initiative regarding state prescription drug monitoring programs, to 

include information regarding how VA intends to measure the outcome of the pilot 

programs. Please also elaborate on the Information Technology ‘‘limitations’’ that 

were referenced in regard to the pilot programs. 

22. Please describe the actions, if any, that have been taken to make the VA formulary more consistent with the DoD formulary. 

Questions for the Record From Hon. Keith Rothfus 

1. On September 9, 2013, you testified at a field hearing in Pittsburgh that VA 

would delay taking any administrative disciplinary action relating to the systemic 

failures and mismanagement at the VA Pittsburgh Healthcare System (VAPHS) 

that resulted in the deaths of at least six veterans due to an outbreak of legionella 

until the U.S. Justice Department concluded its criminal investigation. Then, on November 21, 2013, the Justice Department announced that it had concluded that investigation and that no criminal charges would be brought. It has now been over 

three months since that announcement, and the VA has yet to hold anyone at 

VAPHS accountable. Accordingly, please provide a detailed explanation of what VA 

has done internally to investigate those responsible for these preventable deaths, 

what VA has left to be done to conclude that investigation, and a date certain by 

which the families of the victims and Members of Congress can expect that the VA 

will take such administrative disciplinary action. 

2. On November 26, 2013, following the conclusion of the Justice Department’s investigation into the legionella outbreak at VAPHS, Senator Pat Toomey and I sent 

a letter to Secretary Eric Shinseki requesting information about what administrative disciplinary action the VA planned to take, if any. To date, though, over three 

months later, neither Senator Toomey nor I have received any response. Can you 

please explain why the Secretary’s office found it acceptable to not send any response to our inquiry? Is this indicative of how VA and the Secretary’s office views 

Congressional inquiries and oversight generally? 

3. During the hearing on February 26, 2014, you stated that only one death resulted from the legionella outbreak at VAPHS. Yet, the Centers for Disease Control 

and Prevention (CDC) found in its investigation that at least 21 veterans were 

sickened as a result of the outbreak, five of whom died. Moreover, since the CDC 

released its report, a sixth veteran death has been connected to the outbreak as 

well. Accordingly, please provide a detailed explanation why VA has concluded, despite the findings of the CDC, that only one death resulted from the outbreak of 

legionella at VAPHS. 


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LETTER FROM ROBERT A. PETZEL TO HON. DAN BENISHEK

March 13, 2014 

The Honorable Dan Benishek Chairman 

Subcommittee on Health Committee on Veterans’ Affairs 

U.S. House of Representatives Washington, DC 20515 

Dear Mr. Chairman: 

I have reviewed the February 26, 2014, Committee on Veterans’ Affairs, Subcommittee on Health hearing’s unofficial transcript. I am writing to clarify responses I gave to questions during the hearing. 

First, let me state again that the Department of Veterans Affairs (VA) cares deeply for every Veteran we serve. Our goal is to provide the best quality, safe and effective health care our Veterans have earned and deserve. We take seriously any issue 

that occurs at any one of the more than 1,700 VA health care points of care across 

the country. 

I would like to clarify that I made an error when I stated the date of death of 

one of the patients occurred on July 12, 2012, at the VA Pittsburgh Healthcare System. The date of death was July 4, 2012. Further, of the six deaths discussed at 

the hearing, the Veterans Health Administration (VHA) is in possession of five 

death certificates. In the case of the sixth death, the Veteran passed away at a community hospital and VHA does not currently possess the death certificate. As previously reported, one death was attributed to Legionella pneumonia as the primary 

cause of death. I based my testimony on the immediate cause of death. However, 

there was a second patient who had a contributing cause of death listed as 

Legionella pneumonia on the death certificate, but it was not the primary cause of 

death. VA extends its condolences to the families of the Veterans affected by acquiring Legionella in our healthcare system. 

We are committed to doing whatever it takes to minimize the risk of Legionella 

and create the safest environment possible for our nation’s Veterans to heal. 

Additionally, I would like to clarify a response I gave to a question on three 

deaths in Atlanta and the Office of the Inspector General (OIG) findings. There 

were two OIG reports on Atlanta, both published on April 17, 2013. The report titled ‘‘Patient Care Issues and Contract Mental Program Mismanagement Atlanta 

VA Medical Center Decatur, Georgia’’ (Report 12–02955–178) addresses two deaths 

that occurred under contract care; a report titled ‘‘Mismanagement of Inpatient 

Mental Health Care Atlanta VA Medical Center Decatur, Georgia’’ (Report 12– 

03869–179) addresses one death that occurred at the Atlanta VAMC. When I responded to the question regarding ‘‘three deaths’’ I was referring to deaths mentioned in Report 12–02955–178, not the death at the Atlanta VAMC Inpatient Mental Health Unit. It was my intent to say that the OIG report numbered 12–03869– 

179 did state that the staff’s failure to watch patients may The Honorable Dan 

Benishek have contributed to the patient’s death on the Atlanta VAMC Inpatient 

Mental Health Unit. VHA recognizes the significance of the tragic events that occurred in Atlanta and has taken action there to improve mental health services for 

Veterans. VHA’s first priority is the delivery of high quality care to our Nation’s 

Veterans including access to quality mental health care. 

I request that this letter be made an official part of the record. Thank you for 

your assistance. 

Sincerely, 

Julia Brownley, 

Ranking Member 

f 

DELIVERABLES 

Context of Inquiry: On February 26, 2014. Dr. Robert Petzel, Dr. Robert Jesse, 

Dr. Rajiv Jain, Dr. Madhulika Agarwal and Mr. Phillip Matkovsky testified before 

the HVAC–Health committee at a hearing titled: ‘‘VA Accountability: Assessing Actions Taken in Response to Subcommittee Oversight’’. There were seven deliverables 

from the hearing. 

Question 1: Please provide the complete list of specialty care services that have 

not yet implemented productivity standards. 

Response: Specialties scheduled for implementation during the 3rd and 4th quarters this year: 

• Cardiology 


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• Pulmonary/Critical Care 

• General Surgery 

• Physical Medicine and Rehab 

• Anesthesiology 

• Emergency Medicine 

• Laboratory/Pathology 

• Geriatrics 

Question 2: Please provide an examination of the need for and potential incorporation of whistleblower protections for Veterans reporting military sexual trauma. 

Response: As noted by Committee Member Kuster, the Department of Defense 

is currently reforming policies regarding Servicemembers’ protection against retaliation after reporting experiences of military sexual assault. VHA cannot conceive of 

a scenario where a parallel set of policies in VHA would be necessary. 

• Disclosures of MST to a VA staff member would be considered protected 

health information and thus subject to the provisions of the Health Insurance 

Portability and Accountability Act (HIPAA). Penalties for unauthorized use of 

medical record information are already covered under HIPAA and do not need 

to be duplicated by VA MST-specific whistleblower protections. 

• VA does provide care for some active duty Servicemembers or Reservists who 

later return to active duty. In these cases, VA medical record information may 

be shared with the Department of Defense. If a disclosure of MST noted in a 

Servicemember’s medical record subsequently led to retaliation against the 

Servicemember, the transgression would presumably be covered under the Department of Defense’s whistleblower protections. Again, there is no need for a 

parallel set of VA policies. 

• Eligibility for VA care is independent of any Department of Defense disciplinary or other proceedings, unless the Veteran was to ultimately receive an 

Other Than Honorable or Dishonorable discharge. If this discharge were the result of retaliation, this would also presumably be covered by the Department 

of Defense’s whistleblower protections. 

Question 3: The Circumstances surrounding the six members of the SES who 

had ‘‘serious disciplinary actions’’ taken against them over the last two years. 

Response: The Department is currently working to provide the circumstances 

surrounding the six members of the SES who has disciplinary actions taken and will 

provide this information as soon as possible. 

Question 4: Provide a report on MST anonymous callers (Mystery Shopper). 

Response: The MST anonymous caller initiative targets a potential barrier to accessing MST-related care: difficulty contacting the MST Coordinator at a VHA 

health care facility. The initiative was first authorized in June 2010, and four 

rounds of review have been conducted since at an approximately yearly interval. 

During each round, two members of the MHS national MST Support Team—one 

female and one male—placed calls to the primary switchboard phone number of 

each facility during normal business hours. Following a standard script, callers 

asked for assistance in reaching the facility MST Coordinator. Calls were rated 

based on the ability of operators and other frontline staff (e.g., clinic clerks) to identify the MST Coordinator, the seamlessness of the transfer, and staff members’ courtesy and sensitivity to callers’ privacy concerns. Each facility was rated as Satisfactory, Marginal, or Unsatisfactory based on results from both calls. All facilities with 

a Marginal or Unsatisfactory rating received detailed feedback on the calls, and, to 

date, have submitted action plans to VA Central Office to address the identified 

issues negatively impacting MST Coordinator accessibility. 

The MST Support Team has taken several steps to assist facilities with preparing 

for the calls and with writing action plans. These include hosting a webinar presentation on the initiative, disseminating tip sheets of strategies on increasing and 

maintaining accessibility, and consulting with MST Coordinators to problem solve 

identified barriers. 

The initiative has been successful in improving nationwide MST Coordinator accessibility. In Round 4 (Aug–Sep 2013), 83.6% of facilities were judged to have Satisfactory accessibility, 13.6% Marginal, and 2.9% Unsatisfactory. These results represent a nearly 30 percentage point improvement in Satisfactory accessibility and 

16 percentage point drop in Unsatisfactory accessibility since Round 1 (Jul–Aug 

2010). 

Question 5: Provide the FY 2013 Office of Productivity and Efficiency’s staffing 

standard report for MST (measuring the number of MST patients that VA facilities 

are treating and the staff resources available to treat them); 


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Response: The Annual Report on Counseling and Treatment for Military Sexual 

Trauma (MST) for Fiscal Year (FY) 2013 is currently being reviewed and we will 

provide the report to you as soon as it is available. 

Question 5a: Please also provide information paper on the .2 FTE for MST. 

Response: Please see below for the methods and results regarding decision to 

have .2 FTE for MST. 

Methods 

• The VA MHS MST Support Team completes an annual report to determine 

the number of trained full time equivalent employees (FTEEs) required to meet 

the mental health needs of Veterans who have experienced MST, to fulfill the 

requirements of 38 United States Code, Section 1720D(e). Because MST is associated with a variety of mental health conditions and is treated across multiple 

outpatient treatment settings, we could not rely solely on the number of providers in a given mental health service line or clinic. Therefore, we relied on 

methods developed by the VA Office of Productivity, Efficiency, and Staffing 

(OPES) to quantify workload associated with MST-related mental health care 

and calculate the effective number of FTEEs associated with this care at each 

VA Health Care System (HCS). From this we created a metric so that staffing 

levels could be compared across facilities. 

• Each VA HCS varies in the number of Veterans that it serves who have experienced MST and therefore varies in the demand for MST-related mental health 

care. To enable comparisons across facilities, we calculated a ratio of provider 

staffing against population size: the total FTEEs providing MST-related mental 

health care for every 100 Veterans with positive MST screens. It is important 

to note that not all Veterans with a positive MST screen will want treatment 

and among those that do request care, the amount of MST-related care required 

by each Veteran will vary due to the range of mental health conditions associated with MST. But in general, a larger staffing ratio indicates greater staffing 

and availability of MST-related mental health services. 

• We examined the amount of MST-related mental health care that each VA 

HCS provided and ranked facilities on two indicators: 1) the proportion of Veterans with a positive MST screen who received any MST-related mental health 

care; and 2) the median number of visits among patients who received MSTrelated mental health care. We identified health care systems that ranked in 

the top 25% for both indicators. We then used staffing ratio data from these 

‘‘high volume’’ VA health care systems to establish the benchmark. 

• The benchmark of 0.2 FTEE per 100 Veterans (or 2 FTEE per 1,000 Veterans) who experienced MST is based on a comparison with these ‘‘high volume’’ 

VA health care systems. This benchmark is within two standard deviations of 

the average staffing ratio at high volume health care systems. Even staffing levels that are only a portion of a single FTEE represent portions of workload from 

several different providers due to the wide range of mental health conditions 

and clinic settings associated with MST-related mental health care. 

Results 

• All VA health care systems provide MST-related care to both female and male 

Veterans and all VA health care systems have mental health providers knowledgeable in the treatment of MST-related mental health conditions. In the most 

recent analysis, 99 percent of VA health care systems were at or above the established benchmark for MST-related mental health staffing capacity. Over 

64,000 Veterans received MST-related mental health care from a VA health 

care facility. These Veterans received a total of over 693,000 MST-related mental health care visits from over 17,950 individual providers. Not all of those 

17,950 individual providers, however, spent all of their clinical hours delivering 

MST-related mental health care. The care delivered by those providers was 

equivalent to 580 FTEEs. 

Question 6: Provide the committee with information about the VA employees 

that were held accountable for patient deaths at the Augusta VAMC and the Atlanta VAMC. 

Response: Disciplinary actions for Atlanta and Augusta are below: 

Disciplinary Actions 

Atlanta VAMC 

Chief of Staff—Reprimand 

Associate Director—Reprimand 

Associate Director/Nursing and Patient Care Services—Reprimand 

Chief, Mental Health Service Line—Reassigned 

Mental Health Inpatient Nurse Manager—Reprimand 


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Associate Nurse Executive/Mental Health and Geriatrics—Reprimand 

Mental Health Inpatient Unit Medical Director—Admonishment 

Former Medical Center Director—Retired 

Veterans Integrated Service Network (VISN) Chief of Mental Health Services—Retired 

Augusta VAMC 

Chief of Staff-Received performance Counseling (Voluntarily resigned from 

position) 

Question 7: Please provide the timeline for VHA to contribute to the State Prescription Drug Monitoring Program? 

Response: VA participation with State Prescription Drug Monitoring Program is 

estimated to begin August 2014. This is predicated on a contract award by May 5, 

2014, with a contract start shortly after award. The timeline includes achieving 

Milestone 2 (development enters implementation phase) by May 30, with code 

changes to other patches and Medication Order Checking Application (MOCHA 2.0) 

completed, documentation updated, and identification of additional test sites by the 

end of June. It is expected that this work would enter the national release process 

near the middle of July with testing and deployment leading to a mid-August completion. The State Drug Monitoring Program patch is dependent on MOCHA 2.0 

which will deploy in waves between March 24, 2014 and June 16, 2014, as well as 

a titration management patch that will start simultaneously with the State Drug 

Monitoring Program patch. There are potential risks of delays to the August 2014 

start date that could arise from dependencies that include contract start date and 

unforeseen technical issues with states that are not part of the test site process. The 

VA Office of Information and Technology is responsible for oversight and management of software development and deployment for this program. 

Æ 


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