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98–694 2016

EVALUATING VA PRIMARY CARE DELIVERY, 

WORKLOAD, AND COST 

HEARING 

BEFORE THE

SUBCOMMITTEE ON HEALTH 

OF THE

COMMITTEE ON VETERANS’ AFFAIRS 

U.S. HOUSE OF REPRESENTATIVES 

ONE HUNDRED FOURTEENTH CONGRESS 

FIRST SESSION 

THURSDAY, OCTOBER 22, 2015 

Serial No. 114–39 

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 

DAN BENISHEK, Michigan 

TIM HUELSKAMP, Kansas 

MIKE COFFMAN, Colorado 

BRAD R. WENSTRUP, Ohio 

JACKIE WALORSKI, Indiana 

RALPH ABRAHAM, Louisiana 

LEE ZELDIN, New York 

RYAN COSTELLO, Pennsylvania 

AMATA COLEMAN RADEWAGEN, 

American Samoa 

MIKE BOST, Illinois 

CORRINE BROWN, Florida, Ranking 

Minority Member 

MARK TAKANO, California 

JULIA BROWNLEY, California 

DINA TITUS, Nevada 

RAUL RUIZ, California 

ANN M. KUSTER, New Hampshire 

BETO O’ROURKE, Texas 

KATHLEEN RICE, New York 

TIMOTHY J. WALZ, Minnesota 

JERRY MCNERNEY, California 

JON TOWERS, Staff Director 

DON PHILLIPS, Democratic Staff Director 

SUBCOMMITTEE ON HEALTH 

DAN BENISHEK, Michigan, Chairman 

GUS M. BILIRAKIS, Florida 

DAVID P. ROE, Tennessee 

TIM HUELSKAMP, Kansas 

MIKE COFFMAN, Colorado 

BRAD R. WENSTRUP, Ohio 

RALPH ABRAHAM, Louisiana 

JULIA BROWNLEY, California, Ranking 

Member 

MARK TAKANO, California 

RAUL RUIZ, California 

ANN M. KUSTER, New Hampshire 

BETO O’ROURKE, Texas 

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public hearing records 

of the Committee on Veterans’ Affairs are also published in electronic form. The printed 

hearing record remains the official version. Because electronic submissions are used to 

prepare both printed and electronic versions of the hearing record, the process of converting 

between various electronic formats may introduce unintentional errors or omissions. Such occurrences are inherent in the current publication process and should diminish as the process 

is further refined. 


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C O N T E N T S 

Thursday, October 22, 2015 

Page 

Evaluating VA Primary Care Delivery, Workload, and Cost ............................... 1 

OPENING STATEMENT 

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

Hon. Mark Takano .................................................................................................. 3 

WITNESSES 

Randall B. Williamson, Director, Healthcare, GAO .............................................. 4 

Prepared Statement ......................................................................................... 25 

Thomas Lynch M.D., Assistant Deputy Under Secretary for Health Clinical 

Operations, VHA, U.S. Department of Veterans Affairs .................................. 5 

Prepared Statement ......................................................................................... 36 

Accompanied by: 

Richard C. Stark M.D., Director of Primary Care Operations, VHA, 

U.S. Department of Veterans Affairs, 

And 

Gordon Schectman M.D., Chief Consultant for Primary Care 

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


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EVALUATING VA PRIMARY CARE DELIVERY, 

WORKLOAD, AND COST 

Thursday, October 22, 2015 

U.S. HOUSE OF REPRESENTATIVES

COMMITTEE ON VETERANS’ AFFAIRS

SUBCOMMITTEE ON HEALTH

Washington, D.C. 

The subcommittee met, pursuant to notice, at 10:00 a.m., in 

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

[chairman of the subcommittee] presiding. 

Present: Representatives Benishek, Bilirakis, Roe, Huelskamp, 

Coffman, Wenstrup, Abraham, Takano, Ruiz, and Kuster. 

Also Present: Representative Walorski. 

OPENING STATEMENT OF CHAIRMAN DAN BENISHEK 

Dr. BENISHEK. The subcommittee will come to order. 

Before we begin, I would like to ask unanimous consent for our 

friend and colleague and member of the full committee, Congresswoman Jackie Walorski, to sit on the dais and participate in today’s hearing. And she will be joining us shortly. Without any objection, so ordered. 

Thank you all for joining us for today’s subcommittee hearing 

Evaluating VA Primary Care Delivery, Workload, and Cost. 

During today’s hearing, we will be discussing the findings and 

recommendations of a Government Accountability Office report regarding the primary care that is provided to veteran patients at 

Department of Veterans Affairs’ medical facilities across the country. 

I was glad to join many of my fellow committee members in requesting this report which will be publicly released today and I 

commend the GAO for their work. 

During their investigation, the GAO found the department 

lacked reliable data on how many patients VA primary care providers were seeing. The GAO also found that VA had failed to put 

appropriate oversight processes in place to verify whether the primary care data that the VA medical facilities were reporting was 

accurate or to monitor the primary care that was being provided 

to veteran patients. 

For six of the seven VA medical facilities that the GAO visited, 

panel size varied from a low of a thousand patients per provider 

to a high of 1,338 patients per provider. The GAO found that the 

cost of the care in VA primary care clinics also varied widely. 


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VA has been unable to respond to repeated requests for cost of 

care information by me and other members of this committee for 

more than a year now. 

But the GAO found that in fiscal year 2014, VA expenditures per primary care encounter ranged from a low of $150 to a high of $396 

across the system and expenditures per patient ranged from a low 

of $558 to a high of $1,544. 

Data inaccuracies, oversight, and management failures and a 

lack of continuity or uniformity in care or costs across the country 

have sadly come to characterize the VA healthcare system over the 

last several years. 

Nonetheless, the GAO findings are alarming. For many veteran 

patients, an appointment with the primary care clinic is the first 

appointment they have at a VA medical facility. For them, primary 

care is the gateway to VA care. 

Without accurate data and effective oversight, the VA cannot 

guarantee that VA primary care providers are productively providing high-quality care or that veteran patients are receiving 

timely access to care. And without minimizing variations in costs 

across the system, the VA cannot guarantee that primary care is 

being delivered efficiently from VA facility to VA facility. 

My suspicion based on my 20 years of work as a contract physician at a rural VA medical center and three years as chairman of 

this subcommittee is that primary care is not being provided efficiently or effectively at far too many VA medical facilities and as 

a result, far too many of our veterans are falling through the 

cracks. 

Meanwhile, software that could have addressed some of VA’s primary care data reliability issues were shelved after the department 

had spent almost $9 million on it supposedly because of a lack of 

the one and a half million dollars in funding that was required to 

implement it nationally. 

What is more, the department plans to take until September of 

2016 to issue new primary care guidance and until September of 

2018 before findings and decisions regarding primary care encounter and expenditure data to strengthen primary care monitoring 

will be made. 

That is unacceptable particularly considering that GAO reported 

that some providers at facilities with high panel sizes have already 

expressed to VA medical center leadership that their ability to provide safe and effective patient care was being hindered by their 

workload. 

The VA must take action today to protect VA primary care patients and to help VA doctors and nurses provide higher quality 

care to our Nation’s veterans. 

I will now yield to Mr. Takano who is sitting in today for our 

ranking member, Ms. Brownley, for any opening statement he may 

have. 


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OPENING STATEMENT OF HON. MARK TAKANO 

Mr. TAKANO. Thank you, Mr. Chairman, for calling this hearing. 

Thank you. 

Today the subcommittee is looking at the efficiency and effectiveness of the department’s ability to deliver primary care to veterans 

enrolled in VA’s primary care. 

Since 2010, VA has provided primary care services through a patient-centric medical home model of care called the patient aligned 

care teams or PACTs. The PACT teams are made up of physicians, 

nurse practitioners, physician assistants as well as support staff. 

This model is designed to improve access, continuity, and care coordination among other things. 

Many veterans seeking mental health services have benefitted 

from this model because they have not been subjected to the stigma 

attached to visiting a mental health clinic. While we have worked 

hard to destigmatize mental health, I understand this is still a 

challenge for many veterans. 

In its written testimony, VA reminds us that it is difficult to 

compare VA’s enrollee population to that of the private sector. VA 

patients are older and sicker than their counterparts and overall, 

20 percent have documented mental health diagnoses. 

In order to get the right care to the right veteran, the VA needs 

to know how many veterans are being treated at each facility. The 

report the GAO released today found that VA data on primary care 

panel sizes are unreliable and that proper oversight mechanisms 

are not in place. 

Due to the absence of reliable panel size data and oversight processes, GAO concluded that this could significantly inhibit VA’s ability to ensure that facilities are providing veterans with timely quality care that is delivered efficiently. GAO also found that VA was 

in violation of federal internal control standards. 

As you know, Mr. Chairman, VA’s primary mission is to provide 

high-quality, safe healthcare to veterans. A top priority for this 

subcommittee is to ensure that VA has the tools and resources it 

needs to enable that to happen. 

I thank the witnesses for their testimony and I look forward to 

hearing from our panel. 

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

Dr. BENISHEK. Thank you. 

Joining us on our first and only panel this morning is Randy 

Williamson, Director of Healthcare for the Government Accountability Office. 

We are also joined by Dr. Thomas Lynch, the VA Assistant Deputy Under Secretary for Health Clinical Operations. And Dr. Lynch 

is accompanied by Dr. Richard Stark, the VA Director of Primary 

Care Operations, and Dr. Gordon Schectman, the VA Chief Consultant for Primary Care Services. 

Thank you all for being here this morning. 

Mr. Williamson, we will begin with you. Please proceed with your 

testimony. 


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STATEMENT OF RANDALL B. WILLIAMSON 

Mr. WILLIAMSON. Thank you, Mr. Chairman and Mr. Takano and 

members of the subcommittee. 

I am pleased to be here today to discuss GAO’s report released 

today on VA’s processes for determining and overseeing workload 

capacity of its primary care teams at its medical centers. 

Primary care services are often the entry point to the VA 

healthcare system for veterans and these services are delivered by 

primary care teams consisting of physicians, nurses, and support 

staff. 

Determining how many patients to which each primary care 

team can reasonably deliver care referred to as the panel size is 

critical to ensure that our Nation’s veterans receive timely, quality 

care and is delivered in an efficient manner. 

For example, if panel sizes are too high for primary care teams 

at a particular facility, this may lead to veterans experiencing 

delays in receiving care, whereas low panel sizes may be associated 

with inefficiency and wasted resources. 

To better ensure that VAMCs have reasonable primary care 

panel sizes, VAMCs are required to record and report panel size 

data including the number of primary care providers, support staff, 

and available exam rooms. 

VA’s central office inputs these data into a model it developed, 

determines the appropriate primary care panel sizes for each 

VAMC, and provides this data to VAMCs. However, VAMCs can 

deviate from these model panel sizes as they see fit. 

We attempted to compare VA’s model panel sizes with actual 

panel sizes for all of its VAMCs, but we found that systemwide, 

some data that VAMCs record and report to central office were inaccurate and unreliable. 

For example, panel size data included patients who had died or 

who had not been seen in the last two years. Also, there were missing data and the number of reported exam rooms were sometimes 

erroneous. Absent accurately reported data, VA’s central office has 

no good way of determining whether primary care panel sizes are 

too high or too low. 

We conducted detailed reviews at seven VAMCs and after correcting reported inaccuracies at six of them, we found that actual 

panel sizes ranged from 23 percent below to 11 percent above the 

model panel sizes that central office determined to be appropriate 

at these locations. 

Panel sizes for these VAMCs ranged from a thousand patients 

per full-time providers to 1,338. VAMC officials attributed the differences to varying degrees of patient demand, staffing shortages, 

and/or exam room shortages. 

Some VAMCs decided to establish lower panel sizes to prevent 

provider burnout and attrition. Other VAMCs with higher panel 

sizes were experiencing staff shortages due to recruiting and retention difficulties associated with rural locations or the inability to 

compete with higher pay offered by the private sector. Also, some 

VAMCs were not affiliated with a university medical school that 

could have provided a supplementary pool of physicians. 

We also found that cost for primary care visits which can be an 

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ered varied widely at VAMCs. The cost per primary care visit varied from $158 to $330 at the seven sites that we visited. 

We also found that oversight to better ensure accuracy of data 

VA submit is basically lacking. Moreover, even if accurate primary 

care panel size data existed, neither VA’s central office nor many 

VISNs perform systematic oversight to identify large gaps between 

the model panel sizes and the actual panel sizes at its facilities. 

Also, cost per visit data is not even considered to be relevant as 

a measure of how well VAMCs are managing the delivery of primary care services. 

Absent meaningful oversight to correct potential imbalances in 

primary care panel sizes, some VAMCs may be putting veterans at 

risk by not providing timely, quality care. 

For example, one VAMC we reviewed with the highest panel 

size, 1,338, had a vacancy rate among its primary care providers 

of 40 percent. Some primary care providers at that facility expressed concern to VAMC leadership that the high panel sizes were 

impeding their ability to provide safe and effective primary care 

services. 

This situation is all too reminiscent of veterans’ access issues 

that have arisen at other VAMCs in the recent past. The problems 

with poor data and insufficient oversight that we noted in the report are precisely why GAO added VHA to our high risk earlier 

this year. 

To correct the issues we noted in this study, we made several 

recommendations to improve data accuracy and establish a more 

robust oversight process. While VA concurred with our recommendations, we are concerned that VA may not be moving fast 

enough to make needed improvements. Without major improvements, VA is likely missing opportunities to identify VAMCs that 

warrant further examination and to strengthen the efficiency and 

effectiveness of primary care. 

This concludes my opening remarks. 

[THE STATEMENT OF RANDALL B. WILLIAMSON APPEARS IN THE

APPENDIX] 

Dr. BENISHEK. Thank you, Mr. Williamson. I appreciate it. 

Dr. Lynch, please go ahead. 

THOMAS LYNCH, M.D., ASSISTANT DEPUTY UNDER SECRETARY FOR HEALTH CLINICAL OPERATIONS, VETERANS 

HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS 

AFFAIRS, ACCOMPANIED BY RICHARD C. STARK, M.D., DIRECTOR OF PRIMARY CARE OPERATIONS, VETERANS 

HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS 

AFFAIRS, AND GORDON SCHECTMAN, M.D., CHIEF CONSULTANT FOR PRIMARY CARE SERVICES, VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS 

STATEMENT OF THOMAS LYNCH 

Dr. LYNCH. Good morning, Mr. Chairman, Congressman Takano, 

members of the committee. Thank you for the invitation to discuss 

the delivery of primary care services to veteran patients by the Department of Veterans Affairs. 


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I am accompanied today by Dr. Richard Stark to my left and Dr. 

Gordon Schectman to my far left. 

Mr. Chairman, VHA has over 5.3 million veterans enrolled in 

primary care. We have almost a thousand sites of care and over 

half of the patients receive care in community-based outpatient 

clinics near their homes. 

In many rural areas, we provide care via telemedicine or in mobile medical units. In recent years, we have implemented extended 

hours and all patients have access to after-hours medical advice 

call centers. 

The majority of our patient population has multiple chronic diseases. VA patients are generally older, more complex, less healthy, 

and less socioeconomically well off than those in the private sector. 

Veterans have a higher prevalence of common chronic health conditions such as diabetes, hypertension, and heart disease. 

Overall, 20 percent of veterans have documented mental health 

diagnoses and most of our primary care sites have integrated mental health capabilities so that patients do not have to travel for routine mental health care. In addition, our primary care teams have 

training and experience identifying and managing combat-related 

sequela such as TBI or PTSD. 

Beginning in 2010, as Congressman Takano mentioned, VA 

began providing primary care through the patient-centered medical 

home model of care. VA refers to these as patient aligned care 

teams or PACTs and they involve a team-based approach to 

healthcare. 

Through the PACT, patient care is not only provided in person 

in our clinics but also through virtual modalities such as by telephone, email, or by telemedicine. This team-based model is also 

being used to explore new venues of providing primary care including the provision of care in the home through video technology and 

the use of scribes in the clinic setting to enhance provider productivity and patient satisfaction. 

The more than 8,000 PACTs are made up of a variety of clinical 

and clerical staff including physicians, nurses, and clinical assistants. It has been demonstrated that patients who have been placed 

in well-implemented PACTs have lower hospital readmission rates, 

improved levels of patient satisfaction, and higher results on measures of quality of care. 

Overall, VHA exceeds the private sector in outpatient measures 

of quality such as preventive care and the management of diabetes 

and cardiovascular disease. 

While facilities must have the flexibility to adjust panel size 

based on local resources and patient complexity, central oversight 

is also important. And reliable panel sizes are essential to assure 

continuity and coordination of care. 

VA is appreciative of GAO’s findings in this regard and agrees 

that greater oversight and responsibility for the accuracy of data 

are needed. Through the changes recommended, our processes to 

identify and manage instances of significant variation will be 

strengthened. 

Primary care leadership in VA has also recognized the issues of 

our aging data systems and that this has been a contributing factor 


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with regards to inaccurate documentation and the monitoring of 

panel size. 

In response to this issue, a redesign and reengineering of the 

software that tracks and helps manage patients, the primary care 

management module has been underway and will begin full deployment this year. The updated database will enable both greater control over the accuracy and reliability of panel data and more granular and precise data about staffing and space. 

The report by the GAO also found that primary care cost data 

reported by VHA facilities were reliable but subject to variability. 

And we concur with the GAO’s assessment that VA is missing an 

opportunity to potentially improve the efficiency of primary care 

service delivery through heightened oversight of encounter use and 

costs. 

When considering cost, it is important, however, to note that the 

comprehensive integrated services offered by PACT are generally 

not present in the private sector. PACTs offer integrated mental 

healthcare, social services, coordination with non-VA care as well 

as prevention and wellness support. 

However, many of these services are housed in medical centers 

which are often aging and not properly configured for efficient outpatient care. This makes cost comparisons with non-VA care models difficult to accomplish. 

Mr. Chairman, VA continues to be a veteran-centric organization 

and to deliver patient-centered, world-class healthcare. 

This concludes my testimony and we look forward to further discussing VA primary care with the members of the committee. 

[THE PREPARED STATEMENT OF THOMAS LYNCH APPEARS IN THE

APPENDIX] 

Dr. BENISHEK. Thank you, Dr. Lynch. 

I will yield myself five minutes for questioning. 

Mr. Williamson, this struck me as a result of these data inaccuracies, you only calculated actual panel sizes for six of the seven 

selected facilities where you were able to use updated data provided by each facility and corrected for inaccuracies. 

So the data that the VA gave you initially, that was not adequate 

for you to do any analysis at all; is that right? 

Mr. WILLIAMSON. Correct. We got data from VA, and we looked 

at it and did some further investigation. And we saw a number of 

outliers that just didn’t look right. And as we explored those at the 

sites that we reviewed in detail, we found out indeed there weren’t 

accurate. 

One of the biggest issues was that there were a number of people 

included in the panel sizes that either had died or had not been 

seen in VA for the last two years. 

Dr. BENISHEK. So this data that the VA gave to you, Dr. Lynch, 

that is the same data you used to analyze what is going on there? 

Dr. LYNCH. I think, Mr. Chairman, VA has made some significant changes since this report was put together. And we would be 

happy to discuss those further with you. 

Dr. BENISHEK. Well, it is just of concern to me, while I would like 

to know what those are, but it is of concern to me that, Mr. 

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out going over it a second time and fixing it up so that it made 

some use. So that is of great concern to me. 

And, you know, one of the things I have been trying to do in this 

committee is to try to get the VA to collect more data. 

The panel size to me, I don’t know that that is the biggest issue 

other than the fact that it is a guide to how many providers you 

need, but certainly I think there should be some discretion at the 

local level to decide what the panel size should be so that you prevent this burnout issue and that 1,200 might not be the right number. It may be different in different areas, so I can understand 

that. 

What I am concerned about, though, is a little bit about the cost 

per visit. That seems to be a more important part of it because it 

is difficult for me to figure out. I don’t pretend that there should 

be the same cost per visit as it is in the private sector for many 

of the reasons that both of you discussed. 

But does the cost of the visit, does that include the facility’s 

charges, too? I mean, like the rent of the place that you are at or 

the cost of the building and the utilities, is that all a factor in that? 

Mr. WILLIAMSON. It includes everything including depreciation 

on VA buildings. 

I would also like, Mr. Chairman, to go back to something Mr. 

Lynch said. The VA data that VA gave us is still flawed. I mean, 

the data that VA has in the system and probably the figures that 

VA gave you just now is based on flawed data. 

The improvements that VA have planned including, the new 

PCMM software will correct a lot of the data problems, but the improvements have not been implemented yet. And I take issue with 

the fact that significant improvements have been made, as Dr. 

Lynch suggests. 

Dr. BENISHEK. Well, right. I mean, that is the whole basis of this 

hearing is the fact that they may be making plans on data that has 

no validity. And then to make a plan then when the change in the 

plan doesn’t work, then there is a surprise and, you know, it is a 

problem. But I am just concerned about the variability in the cost. 

Mr. WILLIAMSON. Yes. 

Dr. BENISHEK. And as I understand it, the variability took into 

account already the variability based on location. 

Mr. WILLIAMSON. Right. 

Dr. BENISHEK. And I don’t understand why there is such a huge 

difference in the cost. 

Mr. WILLIAMSON. Well, some of the reasons we were given when 

we performed detailed work at the seven facilities, for example, 

was that some facilities used telehealth and telephone calls extensively while others don’t. And that is one reason why a facility may 

show lower costs. 

Dr. BENISHEK. Does the data include like the severity of the visit 

or the severity of illness of a patient and degree of complexity of 

the visit? That is not included in this from what I can tell. 

Mr. WILLIAMSON. No. It is just basically the cost; that is all the 

costs associated with that particular encounter and the encounter 

itself. 


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Dr. BENISHEK. So, Dr. Lynch, does the VA collect any of that 

data? I mean, like Medicare when you do a patient visit, you have 

to check the complexity of the visit. Does that happen in the VA? 

Dr. LYNCH. Yes, sir, it does. 

Dr. BENISHEK. So where is that data? I haven’t seen anything. 

Dr. LYNCH. So I guess I would ask Mr. Williamson whether their 

data was raw data or whether they adjusted for differences between facilities in terms of the age of the facility or the complexity 

of the patient. 

Mr. WILLIAMSON. We adjusted for geographical labor costs because labor costs are a big factor. Say from Los Angeles versus St. 

Cloud, there is a very big difference in labor costs. So we adjusted 

for labor costs and then used VA data for that. 

Dr. LYNCH. But for age of the facility or complexity of the patient 

population, there probably needs to be some adjustments as well. 

Mr. WILLIAMSON. That is right. That is the reason that you want 

to, if you see big variations, to determine the reasons for variations 

and that is why VA oversight would help identify possible inefficiencies that may be happening at VAMCS. Yes, there are a number of reasons why those costs could vary. 

Dr. BENISHEK. Do you have the data on the complexity of the patient visits, Dr. Lynch? 

Dr. LYNCH. We do, sir. 

Dr. BENISHEK. It would be helpful, I think, for the subcommittee 

to see like what is the average intensity level of the visit because 

there is—I don’t remember exactly the numbers. Maybe Dr. Abraham remembers. He is closer to private practice than I was, you 

know, because they have level one, two, three, four, five outpatient 

visit. 

And, you know, I can understand having complex patients that 

have a higher complexity would cost more, but I think we need to 

have that information on a regular basis to sort of monitor and supervise how the VA is taking care of patients. 

Is there a way of doing that on a regular basis, Dr. Lynch? 

Dr. LYNCH. I would hope we can find a way. Speaking as a clinician, I don’t disagree with you. I think the more data we have to 

identify how best to treat patients, the better off we are going to 

be. So I am not arguing with anything you are saying. 

I think with respect to the GAO report, we are aware of a number of the deficiencies. The PCMM model which either Dr. Stark 

or Dr. Schectman can speak further about will help us basically 

look at panels and make sure they are properly impaneled. It will 

help us work through and eliminate those patients who may have 

died or may not have used VA care. These are all important things. 

We need to know that and you probably need to know it as a committee. 

Dr. BENISHEK. I am sorry. I realize I am over time. I will yield 

now to Mr. Takano. 

Mr. TAKANO. Thank you, Mr. Chairman. 

Mr. Williamson, did I hear you correctly? The chairman asked a 

question that I am interested in about the underutilized space and 

how that factors into your conclusions. 

Did that factor into the cost of care? 


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Mr. WILLIAMSON. No, it didn’t. As you know, many VA facilities 

are old and were built when VA had more of an inpatient model, 

and since VA has converted to an outpatient model, the issue of 

shortage of exam rooms has came up quite a bit. But, in looking 

at cost per encounter, it is going to be hard to factor in exam rooms 

unless you do a specific analysis of that facility. 

Basically, just used the data that VA gave us. 

Mr. TAKANO. So you didn’t factor in the—— 

Mr. WILLIAMSON. No. 

Mr. TAKANO. So the cost differentials wouldn’t—— 

Mr. WILLIAMSON. No. 

Mr. TAKANO. Okay. 

Mr. WILLIAMSON. We used labor costs. 

Mr. TAKANO. Okay. Dr. Lynch, the report references a pilot 

project regarding primary care management model at the primary 

care operations office at selected facilities in 2014. It was mentioned in the chairman’s opening statement. It was planned to be 

implemented agency-wide after resolving certain software interoperability issues. 

Why is the implementation on hold and when will it be implemented systemwide? 

Dr. LYNCH. So I am going to pass this off to Dr. Stark, but I want 

to make the point it is no longer on hold. 

Dr. Stark. 

Mr. TAKANO. It is being implemented now? 

Dr. LYNCH. It is in the process of being implemented. 

Mr. TAKANO. Okay. Dr. Stark, go ahead. 

Dr. STARK. Yes. The PCMM web which is what we call the new 

software that we have developed was deployed at four pilot sites 

a little over a year ago. As a result of that deployment, some problems with interoperability were identified and further work needed 

to be done. 

It was determined that that extra work would result in additional funds being needed to complete the contract. 

Mr. TAKANO. Is $1.5 million? 

Dr. STARK. That is the $1.5 million. 

Mr. TAKANO. Were you able to find that or—— 

Dr. STARK. Yes. 

Mr. TAKANO [continuing]. You were able to implement? 

Dr. STARK. Yes. The Office of Information Technology had to pull 

money from a number of other projects and identified some excess 

funding. And they were able to locate that funding and were back 

on track. And really that resulted in a delay of only two or three 

weeks in the deployment schedule. 

Mr. TAKANO. Okay. So we are moving ahead with an improved 

data collection? This concern over data that is not adequate for the 

GAO, the VA is moving ahead with trying to resolve that? 

Dr. STARK. Yes. This software has been a long time coming. And 

one of the reasons for developing it was to correct some of the 

issues that we had with inaccurate data and replacing the old software that had really been in place for 15 or 20 years and had been 

patched in all kinds of ways over the course—— 


VACREP0180 with DISTILLER
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Mr. TAKANO. Well, this is news I wasn’t expecting to hear. I am 

glad to hear that VA is moving forward with improved data collection so that we can get a better handle on per patient costs. 

You know, the GAO has also found that the VA was in violation 

of federal internal control standards. Dr. Lynch, what are you 

doing to ensure compliance going forward with those standards? 

Dr. LYNCH. The VA is taking this very seriously. Dr. Carolyn 

Clancy who is the interim under secretary for over a year has 

taken that on as one of her tasks to begin addressing the concerns 

that GAO has that have placed us on the high-risk list. And that 

includes looking at policies and implementation of our policies and 

assuring that we have proper data resources. 

Mr. TAKANO. Dr. Lynch, I am very concerned about something 

that has been said in previous testimony in different hearings. I 

understand from testimony by a man named Mr. Giroir or it could 

have been Ms. Giroir, I don’t remember the gender, but this person 

testified that 43 percent of network directors had acting director 

status. Sixteen percent of VHA medical centers lack a permanent 

director. More than two-thirds of network directors, nurse executives, and chiefs of staffs are eligible for retirement, so two-thirds 

of those existing staffers, as are 47 percent of medical center directors. 

As you try to address a topic like this of meeting compliance, 

which to me is a managerial challenge—I know very well what 

happened when I was on the board of a community college and we 

had an acting chancellor and how that acting chancellor was limited in their ability to actually move the institution forward if we 

had acting presidents of campuses. 

But having acting directors of almost half, I have to imagine that 

this has an impact on your ability to make sure that we are in 

compliance with a standard like this. 

Dr. LYNCH. It does and VA is moving to fill those positions as 

rapidly as we can. And we appreciate the help that Congress and 

the committees have given us in creating the leeway to do that. 

But you are absolutely correct. We need to fill those positions. We 

need to get permanent managers in position and help us move the 

system forward. 

Mr. TAKANO. Well, I know you have a challenge because I understand that frequently administrators are compensated at 70 percent below the private sector for comparable positions, but I also 

understand that it has been a real challenge within the VA in 

terms of personnel and your personnel office in a number of different respects. But I would say this is a very critical thing with, 

you know, so many acting administrators. 

Dr. LYNCH. Two things, I think. Number one, there is a bill that 

is currently under consideration which would allow us to use the 

hybrid Title 38 designation for medical center directors, non-physician medical center directors, which will help us increase salaries, 

make positions more desirable. I think we already have one of the 

most desirable missions of any healthcare system in the country, 

which is treating veterans. And I think we have been working with 

H.R. to try to develop a more efficient process to hire people. We 

recognize those as challenges and we have been trying to work on 

those, sir. 


VACREP0180 with DISTILLER
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Mr. TAKANO. I thank you, Mr. Chairman for indulging me, and 

I thank you for your testimony. 

Dr. BENISHEK. I hesitate to say anything because I ran over too. 

Dr. Roe? 

Dr. ROE. Thank you, Mr. Chairman. And thank you all for being 

here today. And the whole point of this hearing is how to more efficiently provide care for veterans. It is primary care, which is the 

entry level for most folks. And the entire country now, medical profession, is undergoing a transformation. Many of us on this panel 

this morning who are physicians started our morning out with the 

American Group Medical Association, representing 175,000 private 

practice doctors around the country. And they are figuring out with 

ACOs and the new payment models, which is pay for performance 

and outcomes, how to negotiate this and how to become more efficient. And I think the VA may still be stuck in the older model. 

And it really needs to look at what is going on out in the private 

sector. 

I want to look at, Dr. Lynch you said a couple of things about 

the VA panels are older and sicker and so forth. Well I just looked 

up at the NIH website while you were saying this and 18.5 percent 

of the population in general 18 and over have mental illness. It 

does not mean they are in treatment but they have mental illness. 

So the incidence is the same as the VA. And if you look at the incidence of a soldier recruited today versus the population in general, 

they are the same. So I do not know that, and I know Mr. 

Williamson we have had an opportunity to talk. And I think that 

in your testimony you stated that the demographics of the VA patients, at least Dr. Lynch did in VA’s written testimony, are consistently different from a majority of the private primary care practices. Is that data accurate? Because I do not believe that it is. I 

think taking care of veterans is like taking care of any other patient. 

Mr. WILLIAMSON. Well as far as setting the panel size at 1,200, 

which is kind of the rule of thumb for VA, VA did an extensive literature search. They made adjustments because of the acuity of 

older patients. They set panel sizes lower than the private sector. 

I am not here to tell you that is right or wrong but that is the reason and the rationale that they gave us. 

Dr. ROE. And a typical panel, and I will just tell you having practiced medicine for 31 years many doctors under-code in the private 

sector. And I will, as we go around, you will find out that we 

under-code what is actually done so our data may not be accurate 

either. You think, well, I do not want Medicare to come in and look 

at all this. So I mean, I know that I probably under-coded—— 

Mr. WILLIAMSON. Yes. 

Dr. ROE [continuing]. The severity of the illness of the patients 

I was taking care of. I heard Dr. Lynch, and I want to expand on 

this a little bit because I believe you all are on to something by 

helping make these panel sizes. Look, the panel size we know with 

VA is about half the size that it is in private practice approximately. And I think you can increase the efficiency and the satisfaction of practice by having someone do two things. One is provide 

an adequate space for the doctors to work, and then an adequate 

support staff. An adequate support staff, I mean, let the doctor be 


VACREP0180 with DISTILLER
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the doctor. And the scribe you are talking about I think every office 

visit I make practically now is that there will be someone there to 

enter the data into the computer. It is an added cost for a practice 

but I also think it adds tremendous efficiencies. How many places, 

how many scribes are you actually, because the medical center 

where I am in Johnson City, Tennessee, I do not think there are 

any. 

Dr. LYNCH. I am going to ask Dr. Schectman to address that 

question. 

Dr. SCHECTMAN. So the concept of using scribes to enhance efficiency, productivity, is a very attractive one. We have explored 

what is happening in the private sector in order to understand better and we have really networked with the advocates of this. There 

are scribes here and there in the VA but what we have done is established a formal pilot in order to—— 

Dr. ROE. There isn’t, is not a formal pilot? I think the Secretary 

said there was the other day. 

Dr. SCHECTMAN. No, no, no, there is. I am saying we have, what 

we have a pilot ongoing now to evaluate scribes—— 

Dr. ROE. Where? Where and how many? 

Dr. SCHECTMAN. There are currently three sites and only about 

four or five providers. 

Dr. ROE. How many? Four or five? 

Dr. SCHECTMAN. Right. So it is a limited—— 

Dr. ROE. So it is nothing. 

Dr. SCHECTMAN. It is limited. 

Dr. ROE. That would be pretty limited when you—— 

Dr. SCHECTMAN. Well, but we are, we are planning on expanding 

it. We have sites who are interested in participating and we are 

planning to add them. And also including a comparison with voice 

technology so that we can really see whether or not—— 

Dr. ROE. Again, the motivation I think is different. Just to give 

you an example, all of us up here are private practitioners. And if 

I am going to see 25 or 30 people a day, and I have got an electronic health record that takes me two minutes or three minutes 

longer to do that than it does, I have added an hour and a half so 

that the last patient is an hour and a half late. The VA does not, 

I do not know how many they saw, but I did just some quick calculations. If you have a panel of 1,000 and you see ten people a 

day, which is not really hitting it too hard, that is 2,000 visits a 

year based on ten months. And that is two visits per person, per 

year. Which as Mr. Williamson said, some people are in and out. 

And I admit, it is hard. So I mean, patients of mine died too and 

I did not know it till they did not come in a year or two and I saw 

their obituary in the paper. I get that is hard to figure out. But 

you will after a year or two figure it out when they have not been 

in. You make a phone call and find out. That is what we did, you 

have not been in for your appointment. 

Dr. SCHECTMAN. We agree with the need to explore this further. 

Dr. ROE. Okay and thank you. I yield back, Mr. Chairman. 

Dr. BENISHEK. Ms. Kuster. 

Ms. KUSTER. Thank you, Mr. Chairman, and thank you to our 

panel for being with us. One of the questions that I wanted to explore has not been discussed yet, and if it is not in the realm of 


VACREP0180 with DISTILLER
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this conversation I am happy to move on. But I know we have 

heard on this panel before about the difficulties with scheduling. 

And it occurs to me that that is one of the primary obstacles to 

running an efficient panel, is knowing that when a physician comes 

in in the morning they are going to be seeing people throughout the 

day and they are not going to be waiting for appointments that 

were canceled. It seems to me a couple of years ago I spoke with 

a vendor who had a very efficient system. They just scheduled the 

most likely to show up in the morning, the less likely to show up 

in the middle of the day, and the least likely to show up at the end 

of the day when they can double or triple book and make for a 

much more efficient day. And I just had a question, is that taken 

into consideration or is it something that is being considered going 

forward so that the physicians that we do have can work in an efficient way? 

Dr. LYNCH. So that specific model, no. But I will let you know 

that VA has awarded the contract for our new medical scheduling 

appointment program. It will be pilot tested in Boise, Idaho to assure that it delivers what we expected it to deliver. We are also in 

the process of implementing some scheduling enhancements, which 

will be rolled out over the next six months to help our schedulers 

work more efficiently and provide better scheduling opportunities. 

VA has also looked at the no show rate, the missed opportunity 

rate. We have several initiatives in place. We do have a program 

and an algorithm that allows us to identify those patients that are 

most likely not to show up for an appointment. Right now the 

strategy we are using is to try to contact those patients and confirm their appointment. But certainly it would be worth looking at 

different scheduling alternatives to see if that would be a useful 

technique as well. 

Ms. KUSTER. And absolutely contacting the patients. I remember 

I was shocked to hear that that had not been going on. So I think 

all of us in the civilian world rely on that reminder, even if it is 

an automated call. 

My other question has to do with the associate providers and the 

use of associate providers, PAs, medical assistants, nurses, and the 

like. Did you look into that in terms of efficiency or were you solely 

focused on the physician panels? 

Dr. LYNCH. I am going to let Dr. Stark take a shot at that. 

Dr. STARK. Yes, currently about 30 percent of our primary care 

providers are non-physicians, so they are nurse practitioners which 

I think is about 24 percent, and physician assistants are about six 

percent. So we make extensive use of those other healthcare professions in primary care and they have been very helpful to us in 

helping us meet the demand. 

Ms. KUSTER. And are they folded into your data? Is a typical 

panel for a nurse practitioner also 1,200 patients? 

Dr. STARK. No. Actually the panel size for a nurse practitioner 

or a physician assistant is generally set at about 75 percent of a 

physician panel. And but nevertheless those, that data is part of 

the panel capacity information that we use. So we take that into 

account. 

Ms. KUSTER. And then the last question I have has to do, again, 

efficiency speaking on behalf of the VISN, the hospital in White 


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River Junction, Vermont. I am in New Hampshire, but most of my 

veteran constituents in the northern part of the state go to the 

Vermont facility. They are having wonderful success with telemedicine. I was surprised to learn actually in mental health, very, very 

effective. Patients, vets are very comfortable once they get settled 

into the chair and have the eye contact. Did you take that into account? And is that a direction that other VISNs could follow for 

greater efficiency, greater effectiveness, and keeping costs down? 

Dr. STARK. Absolutely. We have used telemedicine in a number 

of our sites, particularly in rural areas where it is difficult to recruit providers. You know, telemedicine can really serve a lot of the 

needs of veterans without requiring that face to face visit. In some 

places they have even set up sort of telemedicine hubs where they 

hire it easier to hire staff in a particular location. Those providers 

see a panel of patients at a distant location on a regular basis. So 

it is an effective tool, absolutely. 

Ms. KUSTER. My time is up. But I would also note that they are 

having great success with PT, physical therapy, in a distant location, which I was impressed by. People could just stay at home. So 

thank you very much. Thank you, Mr. Chair. 

Dr. BENISHEK. Dr. Abraham, you are recognized. 

Dr. ABRAHAM. Thank you, Mr. Chairman. I thank the panel for 

being here, and I think we have got three primary care docs here, 

and then a health director here. So this is a good captive audience, 

and I am going to hit this from the private sector like Dr. Roe did. 

Mr. Williamson, you said that these hospitals that were built 

back in the sixties and seventies were more built for our inpatient 

population, and we get that. But when we are having veterans wait 

too long to get an appointment, when they get there too long to see 

the doc or the NP or the PA, you know, I ran a multiphysician 

practice and I really did not care what the docs or the NPs really 

cared about it, I cared about the patient. And how hard would it 

be to open up, let us say, an inpatient room, make that an exam 

room? You have got a bed, you have got a couch. All you need is 

a stool for the doctor to roll around in. I carry the otoscope in my 

right pocket and my stethoscope in my left, and we are there. That 

is such a simple thing to utilize a facility that you already have in 

place and that you already are paying the electricity on anyway. 

So, again, just, you know, common sense. The three docs can tell 

you, we can convert that hospital room into an exam room in 15 

minutes or less and be ready to go to work. And you know, whether 

the NPs or the docs had to climb the stairs to get there, that is 

not really, I really do not care as long as the patient can get there 

and see somebody. 

Going back to Dr. Roe’s comment about the scribes and the 

under-coding, and he is exactly right. Because we get so wrapped 

up in not knowing how to use the software it takes us forever to 

code a visit. A scribe is an expert. They have been trained in that. 

And what I can tell you, we got scribes in my practice, once we 

started using them we never over-coded but we coded appropriately. Revenues went up. We saw more patients because the 

scribe knew what they were doing better with the software than we 

did. So Dr. Schectman, back to your comment. I would advocate, 

and I can show you hard data across the nation where scribes have 


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enhanced profitability in the VA system or in any system, any private business. But more importantly you get to see more patients 

and you get to see more patients in a very effective manner. You 

get to be the doc, as Dr. Roe said. We are not typists and we are 

not certainly scribes. 

And going back to data collection, we have got ICD–10 out right 

now. And if you guys have looked at it, which I know you have, 

ICD–10 has software where you can collect this data on patients 

saying what their diagnosis is, what their treatment outcome is. 

So my point is this. I understand that, you know, you guys are 

a government bureaucracy and you have to move a little slower because you are dealing with taxpayer monies, and we get that. But 

you know, I want to say that from the business model point this 

is not nuclear physics or rocket science. This is pretty simple stuff. 

And when we as private doctors have to actually make a payroll 

and we are responsible for families making a living and taking a 

paycheck home to their children, we know how to do business. And 

the VA could do this. It is not that hard. 

So again, just more of a statement than a question. And again, 

I think Dr. Lynch, you said something about voice recognition software, we are trying to get it with the VA. Well, you know we have 

got that. Dragon Speak or any of those Dragon models, they have 

been working for 15 years and they are wonderful. So, you know, 

in private industry all these things are available and they are 

available now, and I think we need to think about incorporating 

them into the VA system. Thank you, Mr. Chairman. 

Dr. BENISHEK. Thank you. Dr. Ruiz. 

Dr. RUIZ. Thank you, Mr. Chairman, and Acting Ranking Member for holding this. I am not a primary care doc, I am an emergency medicine physician and we were born because the system 

was broken and there was a high demand and people could not see 

their doctors, or there was an emergency that needed immediate 

care. And from there we developed efficiencies within the emergency department to take care of the patients. When there is not 

a bed, we use a gurney in the hallway. We double up. We do whatever it takes to take care of the patients. And I think that has always been my point, and that I want to stress with the VA 

healthcare system, is that we need to move from an institution centric system to a veteran centric, treat the veteran first mentality 

and try to have all the flexibilities that we can to make it work. 

And in saying that I have done a lot of work with physician 

shortages in rural areas in my district and others and I have done 

research on this matter. And when you approach a physician or a 

panel size difference for the healthcare provider there is oftentimes 

a mentality where we need to look at this in the perspective of the 

physician, in other words match the patients, in other words call 

the patients the burden for the physicians to create wellness in the 

physician’s life so that they can have a better experience, right? Or 

you can look at this in a patient perspective and say we need to 

make sure that we have the adequate amount of physicians in the 

pipelines and train the physicians and the staff to meet the patient 

demand. So there is a difference in the perspective. And I know 

that you all understand that. I just want to make sure that that 

is the central point, is that we are looking at this in the perspective 


VACREP0180 with DISTILLER
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of the patients and in the short term utilize whatever means necessary to get them the care, either in the VA facility or outside of 

the VA facility. But give the care the veterans need. Otherwise 

they will end up in the emergency departments because they cannot see their doctors, or because their diabetes got to an extreme 

point, or their mental health has deteriorated and is to a point 

where they need to be institutionalized. 

And one of that things that our country has defined as an adequate ratio in the community is one physician per 2,000 patients 

or people. To be considered medically underserved it is one to 

3,500. So my question to you is where do you get the panel size 

of one to 1,200? And second is have you looked at counting simply 

the full time equivalent physician for a VISN per population, veteran population size of a VISN and just utilize the one to 2,000 

ratio to determine if you have enough physicians within that VA 

system? 

Dr. LYNCH. Dr. Schectman, do you want to—— 

Dr. SCHECTMAN. I appreciate those comments. Regarding panel 

size, there is controversy in terms of what is the right panel size. 

I agree with you, a lot of the literature does suggest, for example, 

the panel size should be 2,000 or greater. There have been push 

back in the literature actually that this is too much, that in fact 

this would require, in order to provide comprehensive care the way 

the patient centered medical homes do this would require providers 

working 20 hours a day really in order to get all the preventive 

care done, as well as the acute care, as well as the chronic care 

done. So the push back has been to lower it. And this article that 

I am thinking about, really, recommended lowering it to 1,700 or 

1,800 for the private sector but noted that in the VA due to the 

complexity of the patients and other issues regarding the way 

teams are configured and the way care is delivered that a panel 

size of 1,200 or 1,300 is very, very appropriate. 

You know, in fact the independent assessment reviewed this 

very, very carefully and devoted pages to describing this issue 

about what is the right panel size. And actually from the AAFP 

took a formula which the AAFP is advocating and applied that to 

the VA and came up with a panel size recommendation very, very 

similar to our model panel capacity. 

So I do not know considering all of the issues involved in terms 

of panel size, I do not know if we are too far off the mark. I think 

it is very hard to compare us to the private sector without really 

a lot of, you know—— 

Dr. RUIZ. Well, there is different comparisons you can make with 

different institutions that provide similar care and departments 

that provide similar care for similar type patients as the VA. I 

think the overall point here is what are you going to do with the 

data? And second of all, do not wait for the data to act. Do not wait 

for the data to get more physicians, more ancillary staff. I mean, 

it is the common sense. It is the patients that are waiting in the 

lobby. It is the patients that have not been seen. It is the patients 

that are waiting that need the care. So do not wait for the data. 

It is good to have the data so you can make better decisions. But 

do not wait for the data. And the end goal is to add more support 


VACREP0180 with DISTILLER
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for the patients not to have a comfortable patient load to make the 

physician’s life better. 

Dr. SCHECTMAN. I agree with you 100 percent. 

Dr. RUIZ. Thank you. 

Dr. BENISHEK. Thank you, Dr. Ruiz. I just want to make a brief 

comment. And that is everyone is saying that the VA patients are 

sicker, but you have not really shown us any data to actually prove 

that. I mean, I understand that, having worked in the VA. But you 

have not shown me a list of, you know, the complications that people have. There is nothing like that. So—— 

Dr. LYNCH. I would refer you to Assessment A of the independent 

assessment, which does address the issue of VA demographics and 

does come to the conclusion that VA patients have a higher comorbidity than those in the private sector. 

Dr. BENISHEK. That is the data I would like to see. 

Dr. WENSTRUP. Thank you, Mr. Chairman. Thank you all for 

being here today. I appreciate it. One of the things I am trying to 

get a grasp on is we talk about this ratio of doctor to patients in 

primary care. You know, it can vary from practitioner to practitioner, and is there a local flexibility to that? And also locally being 

able to try to figure out why within the same facility one is able 

to see more than the other and do it effectively. For example, in 

our practice, you know, we had 26 doctors. If one is seeing 50 patients in a day and another one is seeing 25 there may be a reason 

for it. It may be as simple as you need another medical assistant, 

which more than pays for itself, right? So I am just curious if there 

is that flexibility on a local level to adjust depending, to adjust in 

a couple ways, either give a practitioner more patients if they are 

able or adjust how they are operating to bring that level up? 

Dr. LYNCH. Dr. Stark. 

Dr. STARK. Yes, there is definitely flexibility at the local level. 

That is one of the things that is very important to us, which is why 

our model panel sizes are basically recommendations and kind of 

a starting point and then we allow the local facility to adjust the 

panel sizes to the characteristics of the practice, the characteristics 

of the providers, the resources they have available so that they can 

tailor their resources to what they have to make sure that their 

veterans get the best of care. 

Dr. WENSTRUP. And are the supervisors or administrators of 

these facilities keenly aware of this and working towards that? Or 

does it take the practitioner to bring attention to it? 

Dr. STARK. Well in most cases the primary care leadership is 

very attuned to this and adjusts those panels on a regular basis. 

And we provide them guidance on how to do that as well. 

Dr. WENSTRUP. You know, and there are some models that may 

be similar to the VA setting. I mean, I understand the difference 

between your typical private practice fee for service, etcetera. But 

as far as the proper patient load, you know it seems to me, I know 

in DoD, still serving in the Reserve, there is this move, especially 

in the Army, that we do not want to just be treatment facilities we 

want to be healthcare facilities, and we want to be preemptive, and 

more preventive, and things like that. But very often people do not 

go to the doctor until they are sick and really we may do better 

if we schedule appointments in like for example MDVIP, which 


VACREP0180 with DISTILLER
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used to be owned by Proctor and Gamble. So Secretary McDonald 

should be familiar with it. And it is a program where people do pay 

a fee, but they come in even when they are well to make sure that 

they are being kept up on their medicines and things like that. And 

they limit their number of patients that they see, and they still do 

some fee for service type things, but things that are not covered. 

Well, you know, in the VA it is pretty much all covered. So is there 

a drive towards this? Doctor, you are shaking your head. So please 

weigh in on that. 

Dr. SCHECTMAN. Well actually I was thinking more in terms of 

a comment you made before in terms of developing better regulation, panel management, and so on, and the fact is that being deployed everywhere and so on. And in response, you know, to actual 

previous legislation we now have, you know, clinical managers 

which have been hired, high level, with specifically that job in 

order to make sure panels are managed properly, that data is accurate, that in fact there is an understanding at the front line primary care level in fact that, you know, there is some, they have 

some authority over their panels and they need to be good feedback, and there needs to be this alignment of leadership at every 

level. And these, they are currently being trained. There are training programs that we have developed in the VA specifically for 

this. Dr. Stark is actually one of the major initiators of this. 

Dr. WENSTRUP. Throughout are they physician driven? 

Dr. SCHECTMAN. The program is physician led. 

Dr. WENSTRUP. Okay. That is helpful. But to my other point, too, 

you know, there are models within the private sector that we may 

be wanting to take a look at that say what is the right number and 

are we providing those visits where, you know, hey, you have diabetes and I do not want to see you when you crash, I want to see 

you every four months anyway, you know, and that type of thing. 

Dr. STARK. Yes, the patient centered medical home model or 

PACT is really the embodiment of that philosophy. And so we take 

that very seriously. 

Dr. WENSTRUP. And are there tools to evaluate are we actually 

saving money by doing that? Because I believe that overall we do 

if we are truly a preemptive healthcare facility as opposed to just 

treating. 

Dr. STARK. Yes. We have looked at that. It is still preliminary 

and it is difficult to make those assessments but as Dr. Lynch mentioned earlier, high performing PACTs have lower hospital readmission rates and other indicators of better outcomes that end up 

costing us less. 

Dr. WENSTRUP. Well might I suggest that we maybe look at some 

of those concierge type services that you actually could provide I 

think in the VA, that type of entity that might be helpful for us 

in the long run. Thank you. I yield back. 

Dr. BENISHEK. Dr. Huelskamp. 

Dr. HUELSKAMP. Thank you, Mr. Chairman. I appreciate the subject of the hearing today and the GAO report, which I find very interesting and very insightful. By my count I think that is the, this 

is the 38th report that has documented data inconsistencies. And 

by the way, I just made that number up. But there has been a lot 

of reports on that. And but the question I guess for Dr. Lynch or 


VACREP0180 with DISTILLER
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Dr. Stark, I might add, bluntly, how valid and reliable is the data 

that we have been discussing here in your opinion? 

Dr. LYNCH. I will take a start that I think there have been some 

inconsistencies and they have given us some challenges. I think 

that the new primary care module that will be looking at PACTs 

are going to address some of those inconsistencies, especially in 

paneling patients who may have died or who may not be seeing 

VA, and maybe looking to give us more accurate data and allow us 

to monitor that data. I will let doctor—— 

Dr. HUELSKAMP. My question though was validity and reliability. 

Could you address each of those separately, of the data here? The 

GAO reports vast inaccuracies, but validity and reliability, can you 

distinguish between the two for me? 

Dr. LYNCH. I think we have concurred with the GAO that our 

data is not reliable and therefore there may be some lack of validity. I think however when we look at things at a larger level we 

can get some information but we can get better information and we 

are working on that. 

Dr. HUELSKAMP. And I appreciate that recognition. Because, I 

mean, we have been hearing data back and forth. And if it is not 

reliable, I mean, this discussion is really rather fruitless until we 

have the reliable data. But is there punishment for employees who 

fail to report the data accurately and who is responsible for, finally 

at the end of the day, who at the VA is responsible for the data 

we are discussing? 

Dr. LYNCH. The facilities and central office are responsible for 

the data. Would I blame an individual? Probably not so much as 

our system that has not provided the tools they need to provide us 

accurate information, and that is what we are working on. 

Dr. HUELSKAMP. So who is responsible then? At the end of the 

day, when you go back to your office and say they asked me a lot 

of questions about data. I admitted it was not reliable and probably 

invalid, strike one and two. Who do you call, Dr. Lynch, and say, 

okay, fix this problem? 

Dr. LYNCH. Central office takes ownership for trying to put that 

data together, sir. And we are working to provide new tools to do 

that. 

Dr. HUELSKAMP. Is there any one person? Or who ultimately, 

who do you call? Not central office. I do not know how many people 

work in the central office. But who is responsible? Who is going to 

fix this, in other words? 

Dr. LYNCH. There are a number of offices that are responsible. 

VHA central office is probably the individual group that is responsible for getting you the data that you need, sir. 

Dr. HUELSKAMP. But is there an individual that is in charge of 

this data project? Or it is just a committee of folks? 

Dr. LYNCH. It is a number of people in central office that are trying to work to solve this problem, sir. 

Dr. HUELSKAMP. And so they are all guilty and all responsible or 

all unaccountable? I am just trying to—— 

Dr. LYNCH. I think they are all trying very hard to work through 

a system of data. It is put together in a computer system that was 

never meant to do what it is supposed to do today. 

Dr. HUELSKAMP. And you mention—— 


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Dr. LYNCH. Our computer system goes back to 1985. Our system 

changed significantly in 1995 when we went from inpatient care to 

outpatient care, and our systems have not changed substantially, 

sir. 

Dr. HUELSKAMP. And we are still determining, here trying to figure out what is the appropriate panel size, even though we are not 

for certain we are even measuring panel size, and we are not for 

sure what we—by the way, does an encounter include a phone call? 

Is that one encounter? How do you count that? 

Dr. LYNCH. It can be billed as an encounter, sir, yes. 

Dr. HUELSKAMP. Does an email to a patient, is that an encounter? 

Dr. LYNCH. To my knowledge right now an email does not count 

as an encounter, is that right, Dr. Stark? 

Dr. STARK. If it meets certain criteria for medical decision making it can be coded as an encounter. 

Dr. HUELSKAMP. Do we know what percentage of the encounters 

are, and that is fundamental to the second part of the report in 

terms of the vast wide range of cost. So if a phone call and perhaps 

an email can be an encounter, do you know how many, what percentage of encounters actually fit that—— 

Dr. STARK. About 30 percent of our encounters are by telephone. 

Dr. HUELSKAMP. And what percent are emails? 

Dr. STARK. I do not have that data. That is a relatively new—— 

Dr. HUELSKAMP. Yes, that is only 20 years old. I get that. I am 

just kidding, I do not know how long you have been counting that. 

But in the private sector, do they count that as encounters? Just 

a phone call, a reminder you are going to have an appointment? Or 

something like that? Or—— 

Dr. STARK. Phone calls do count in the private sector. It is a lesser weight encounter than a face to face visit. 

Dr. HUELSKAMP. Okay. I would like a little more followup then 

on the data, breaking that down, what that encounter is. Because 

that was critical to the second part of the GAO report, trying to figure out, we have got this wide range of expenditures. And just to 

let you know, the piggy bank is about empty. So we need to do a 

better job of how we spend this money. I yield back, Mr. Chairman. 

Dr. BENISHEK. Mr. Coffman, you are recognized. 

Mr. COFFMAN. Thank you, Mr. Chairman. Well one thing that is 

not acknowledged in this report is something that I think VHA 

leadership is very good at, is very effective at, without parallel. 

And that is your ability to cut bonus checks to each other. I mean, 

that is extraordinary in the amount of money spent on that for 

whatever reason. 

But let me, as someone who is involved in healthcare on the 

House side, on the Armed Services side, and on this side, that 

when our severely wounded coming out of Iraq and Afghanistan 

are handled different than our severely wounded were, coming out 

of Vietnam. In Vietnam they were stabilized in the military system 

and then they went to the VA for their rehabilitation. Now we 

keep, extend them on active duty for their rehabilitation, unless 

they specifically request to go to the VA which is very rarely done. 

Then they are medically retired so they are under the TriCare system. So I hope we can improve the VA to where we feel confident 


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about putting our war wounded there, but that is certainly not the 

case today. 

What is extraordinary I think about this report, and I think 

about the culture of the VA, is that when mediocrity is legally protected, this is the system you get. The military system, and I am 

21 years in the military, we have a number of former military officers here, some current, Dr. Wenstrup. But it is a merit based system. Let me tell you, Dr. Lynch, you would not survive in the military system. Period. And maybe you were there at one time, and 

I know a lot of people in the VA come from the military, but they 

have forgotten all the values that they learned in the military. And 

let me tell you there are a lot of good people in the rank and file 

of the VA, do not get me wrong. And they are the people that step 

forward as whistleblowers that we are trying to protect here on 

this committee from retaliation from leaders like yourselves. And 

so it is just extraordinarily disappointing that, what we are seeing 

today. We need to make the Choice program work. I think the 

Choice program will make you better. That the fact I think you 

take the veterans of this country for granted. And I think that having some level of competition will be helpful. And I think we need 

at the end of the day to have some system when we get the Choice 

program to work that the VA is not very cooperative in making it 

work that that demand needs to reflect if relative demand to the 

VISN, if people prefer the Choice program to the VISN then we 

need to bring down the number of employees in the VA for that 

specific VISN. That will come eventually. 

Let me just reference the report. The GAO report indicated that 

in its comments, well, to this report, VA did not provide information on how it plans to address unreliable panel size data accountability. In response GAO recommended that VA specifically assign 

responsibility for verifying each facility’s reported panel size data. 

Who should have this responsibility? And when will VA publish its 

guidance identifying those individuals? Dr. Lynch. 

Dr. LYNCH. So that would fall to Dr. Stark and his office. 

Mr. COFFMAN. Okay. 

Dr. LYNCH. And we are in the process of validating our data as 

we implement the new PCMM web system to monitor our panel 

sizes. That is part of the process to improve the accuracy of our 

data. 

Mr. COFFMAN. And Dr. Lynch, why do you think that the culture 

of the VA is what it is today? That why we get the scandal after 

scandal after scandal in the VHA system? Why do we have the 

wait time system that, where there was manipulation of the wait 

time for appointments in order to get cash bonuses? And that went 

all the way up, and I believe that the head of the Phoenix hospital 

has, I do not think she has been fired yet, or do you know what 

the status of that person is? I understand they are on paid leave, 

can you speak to that? 

Dr. LYNCH. I think the former director has been terminated, sir. 

Mr. COFFMAN. Has been terminated? 

Dr. LYNCH. Yes. 

Mr. COFFMAN. Okay. Mr. Chairman, I yield back. 

Dr. BENISHEK. Thank you. Ms. Walorski. 


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Ms. WALORSKI. Thank you, Mr. Chairman. Dr. Lynch, several 

months ago we did a hearing, I do not even know, it could have 

even been last year. I do not remember. But we talked about the 

issues on the credentialing process for vendors and some of the confusion that happened around the country with unauthorized vendors being in different places and that kind of thing. So I have 

been working on legislation that I introduced that would create a 

uniform framework for enabling the presence of medical vendors. 

This is not necessarily a new issue. But as you examine ways to 

reduce the administrative burdens and improve efficiencies in your 

VMACs, have you considered creating a standard framework for 

vendor access? Has that been talked about? 

Dr. LYNCH. We have been working following those initial meetings to come up with a process that allows us to have full eyes on 

what is coming into our institution, where it is coming from, and 

where it is going. Yes, Congresswoman. 

Ms. WALORSKI. Okay. Are you looking at solutions from the private sector organizations to help streamline that process? 

Dr. LYNCH. I was not part of the group. I cannot confirm that. 

But I would suspect we have been looking at the private sector. We 

have been doing that with increasing frequency now. 

Ms. WALORSKI. And then I would ask you this. I know you are 

not directly on it. But are there any things that you have heard 

that have come out of any of those meetings where Congress can 

be a partner in accomplishing that goal? 

Dr. LYNCH. I have not heard of any specific asks for Congress but 

we certainly keep that in mind. 

Ms. WALORSKI. Okay. And could you at least check on it and get 

back to us? 

Dr. LYNCH. I will. 

Ms. WALORSKI. Okay. I appreciate that. And then I have a question, a final question, on the independent assessment that was released a few weeks ago concluded that VHA and the Office of Information Technology, which I have asked about many times, are not 

effectively collaborating, which has hindered VA’s ability to ensure 

IT investments align with its healthcare objectives. So who within 

the VHA is responsible for coordinating and establishing those objectives between those two offices? 

Dr. LYNCH. So right now we have a new head of OI&T, Ms. Laverne Counsel. I think I can honestly say we have a new sheriff 

in town who has—— 

Ms. WALORSKI. On IT? 

Dr. LYNCH. On IT. 

Ms. WALORSKI. Okay. 

Dr. LYNCH. Who has begun to take an interest in issues such as 

collaboration and understanding how the different parts of the organization can work together. I suspect at this point in time that 

the lead for those communications would probably be Dr. Shulkin, 

but I suspect it will also move down as the more specific needs are 

identified. But there has been a change in attitude—— 

Ms. WALORSKI. And you welcome that change? 

Dr. LYNCH. Pardon? 

Ms. WALORSKI. And you welcome that change? 

Dr. LYNCH. I do welcome that change. 


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Ms. WALORSKI. And I think there has to be real change and that 

there has to be a structural change to be able to enhance those 

interagency cooperations because of the fact the GAO report has 

talked about this as being a serious issue before. I have asked 

many, many times on this committee prior to this new IT person 

about, specifically about IT because so much money has gone into 

it that has been tax money. There has not been a whole lot of accountability and transparency and there has not been a whole lot 

of interagency cooperation. Also, I would hope if you could take 

that message back, I know you are not specifically directed to, but 

I would hope that we would see improvement in those two. And 

again, so that the end goal is helping the veteran get the 

healthcare they were promised. And with that, Mr. Chairman, I 

yield back. 

Dr. BENISHEK. Thank you, Ms. Walorski. I want to thank all of 

you for being here today to give us your testimony, Mr. Williamson, 

Dr. Lynch, Dr. Stark, and Dr. Schectman. I think you pretty much 

got the idea that a lot of us are very frustrated about the rate of 

change or the pace of change. The reassurances that you are on it, 

you know, are all well and good, Dr. Lynch. And you know, I believe you are sincere. It is just that at this level here we get very 

frustrated by the pace of the actual change. And you know, Mr. 

Williamson has just put out the report today, and all of a sudden 

we find out there has already been change in the way that they are 

going to do it. They are implementing the new software. But we 

have not really seen the results of that. So we would like to see—— 

Dr. LYNCH. I think I would say, Mr. Chairman, we welcome the 

opportunity to come back and share with you the results that we, 

our findings as we implement that software. 

Dr. BENISHEK. Yes. Well, I am hopeful that that will be soon. So 

if there are no further questions, you all are excused. I ask unanimous consent that all members have five legislative days to revise 

and extend their remarks and to include extraneous material. And, 

without objection, so ordered. The hearing is now adjourned. 

[Whereupon, at 11:17 a.m., the committee was adjourned.] 


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Æ 


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