89–006 

115TH CONGRESS REPORT " ! HOUSE OF REPRESENTATIVES 2d Session 115–1034 

TO AMEND TITLE 38, UNITED STATES CODE, TO IMPROVE THE PRODUCTIVITY OF THE MANAGEMENT OF DEPARTMENT OF VETERANS AFFAIRS 

HEALTH CARE, AND FOR OTHER PURPOSES 

NOVEMBER 16, 2018.—Committed to the Committee of the Whole House on the 

State of the Union and ordered to be printed 

Mr. ROE of Tennessee, from the Committee on Veterans’ Affairs, 

submitted the following 

R E P O R T 

together with 

MINORITY VIEWS 

[To accompany H.R. 6066] 

[Including cost estimate of the Congressional Budget Office] 

The Committee on Veterans’ Affairs, to whom was referred the 

bill (H.R. 6066) to amend title 38, United States Code, to improve 

the productivity of the management of Department of Veterans Affairs health care, and for other purposes, having considered the 

same, report favorably thereon with an amendment and recommend that the bill as amended do pass. 

CONTENTS 

Page 

Purpose and Summary ............................................................................................ 2 

Background and Need for Legislation .................................................................... 3 

Hearings ................................................................................................................... 5 

Subcommittee Consideration .................................................................................. 6 

Committee Consideration ........................................................................................ 6 

Committee Votes ...................................................................................................... 6 

Committee Oversight Findings ............................................................................... 6 

Statement of General Performance Goals and Objectives .................................... 7 

New Budget Authority, Entitlement Authority, and Tax Expenditures ............. 7 

Earmarks and Tax and Tariff Benefits .................................................................. 7 

Committee Cost Estimate ....................................................................................... 7 

Congressional Budget Office Estimate ................................................................... 7 

Federal Mandates Statement ................................................................................. 9 

Advisory Committee Statement .............................................................................. 9 

Constitutional Authority Statement ...................................................................... 9 

Applicability to Legislative Branch ........................................................................ 10 

Statement on Duplication of Federal Programs .................................................... 10 

Disclosure of Directed Rulemaking ........................................................................ 10 


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Section-by-Section Analysis of the Legislation ...................................................... 10 

Changes in Existing Law Made by the Bill as Reported ...................................... 11 

The amendment is as follows: 

Strike all after the enacting clause and insert the following: 

SECTION 1. DEPARTMENT OF VETERANS AFFAIRS HEALTH CARE PRODUCTIVITY IMPROVEMENT. 

(a) IN GENERAL.—Subchapter I of chapter 17 of title 38, United States Code, is 

amended by inserting after section 1705A the following new section: 

‘‘§ 1705B. Management of health care: productivity 

‘‘(a) RELATIVE VALUE UNIT TRACKING.—The Secretary shall track relative value 

units for all Department providers. 

‘‘(b) CLINICAL PROCEDURE CODING TRAINING.—If the coding accuracy of a Department provider within a clinical area of responsibility of the provider falls below the 

minimum threshold set by the Secretary, the Secretary shall require the Department provider to attend training on clinical procedure coding. 

‘‘(c) PERFORMANCE STANDARDS.—(1) The Secretary shall establish for each Department facility—— 

‘‘(A) in accordance with paragraph (2), standardized performance standards 

based on nationally recognized relative value unit production standards applicable to each specific profession in order to evaluate clinical productivity at the 

provider and facility level; 

‘‘(B) remediation plans to address low clinical productivity and clinical inefficiency; and 

‘‘(C) an ongoing process to systematically review the content, implementation, 

and outcome of the plans developed under subparagraph (B). 

‘‘(2) In establishing the performance standards under paragraph (1)(A), the Secretary—— 

‘‘(A) may incorporate values-based productivity models and may incorporate 

other productivity measures and models determined appropriate by the Secretary; and 

‘‘(B) shall take into account non-clinical duties, including with respect to 

training and research; 

‘‘(C) shall take into account factors that impede productivity and efficiency 

and, in developing remediation plans under paragraph (1)(B), shall incorporate 

action plans to address such factors. 

‘‘(d) DEFINITIONS.—In this section: 

‘‘(1) The term ‘Department provider’ means an employee of the Department 

who has been appointed to the Veterans Health Administration as a physician, 

a dentist, an optometrist, a podiatrist, a chiropractor, an advanced practice registered nurse, or a physician’s assistant acting as an independent provider. 

‘‘(2) The term ‘relative value unit’ means a unit for measuring workload by 

determining the time, mental effort and judgment, technical skill, physical effort, and stress involved in delivering a service.’’. 

(b) CLERICAL AMENDMENT.—The table of sections at the beginning of such chapter 

is amended by inserting after the item relating to section 1705A the following new 

item: 

‘‘1705B. Management of health care: productivity.’’. 

(c) REPORT.—Not later than one year after the date of the enactment of this Act, 

the Secretary of Veterans Affairs shall submit to Congress a report on the implementation of section 1705B of title 38, United States Code, as added by subsection 

(a). Such report shall include, for each professional category of Department of Veterans Affairs providers, the relative value unit of such category of providers at the 

national, Veterans Integrated Service Network, and facility levels. 

(d) COMPREHENSIVE STAFFING MODELS.—Not later than one year after the date 

of the enactment of this Act, the Secretary of Veterans Affairs shall develop comprehensive staffing models for all Department of Veterans Affairs medical centers. 

PURPOSE AND SUMMARY

H.R. 6066, as amended, a bill to amend title 38, United States 

Code (U.S.C.), to improve the productivity of the management of 

Department of Veterans Affairs (VA) health care, and for other 

purposes, would require VA to take certain steps to improve the 


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1 VA Office of the Inspector General 11–01827–36, December 2012, ‘‘Audit of Physician Staffing Levels for Specialty Care Services,’’ https://www.va.gov/oig/pubs/VAOIG-11-01827-36.pdf. 2 Ibid. 

3 Ibid. 

4 CMS Alliance to Modernize Healthcare Federally Funded Research and Development Center, 

September 1, 2015, ‘‘Independent Assessment of the Health Care Delivery Systems and Management Processes of the Department of Veterans Affairs,’’ https://www.va.gov/opa/choiceact/documents/assessments/Integrated_Report.pdf. 5 January 12, 2015, National Health Policy Forum, ‘‘The Basics: Relative Value Units,’’ https:// 

www.nhpf.org/library/the-basics/Basics_RVUs_01-12-15.pdf. 6 Ibid. 

productivity and efficiency of VA medical facilities. Representative 

Brad Wenstrup of Ohio introduced H.R. 6066 on June 8, 2018. 

BACKGROUND AND NEED FOR LEGISLATION

The Committee believes that VA medical facilities must be wellstaffed and achieve a high level of productivity and efficiency in 

order to maximize access to care for veteran patients and ensure 

a prudent use of taxpayer dollars in support of the VA healthcare 

system. However, the Committee is alarmed by several analyses 

over a multi-year period that have called into question how well 

VA tracks and monitors provider staffing, productivity, and efficiency across the VA healthcare system. 

In 2012, the VA Inspector General (IG) issued a report on staffing for specialty care services, which found that VA lacks an effective staffing methodology to ensure appropriate staffing levels for 

specialty care services.1 In this report, the IG also found that VA 

lacks productivity standards for all specialties and that VA medical 

center leads had failed to develop staffing plans.2 This led the IG 

to conclude that, ‘‘VHA’s lack of productivity standards and staffing 

plans limit the ability of medical facility officials to make informed 

business decisions on the appropriate number of specialty physicians to meet patient care needs, such as access and quality of 

care.’’ 3

In 2015, the VA Independent Assessment of the Health Care Delivery Systems and Management Processes (Independent Assessment) released a report on staffing and productivity, which found 

that VA specialty providers are less productive than their private 

sector counterparts on two industry measures—encounters and relative value units (RVUs).4 RVUs are a commonly used measure of 

a provider’s productivity that take into account the time, technical 

skill, mental effort, and stress that are needed for a clinician to 

provide a given clinical service.5 The Independent Assessment also 

found that VA lacked staffing standards; that VA specialty physician staffing levels are lower than industry ratios for most specialties; that the number of patients assigned to VA primary care providers is lower than the private sector benchmark for patients of 

a similar acuity; and that insufficient exam room space, poor configuration of clinical areas, and unsatisfactory clinical and administrative support staff ratios limited productivity and efficiency—and, 

therefore, access—across the VA healthcare system.6

In 2017, the Government Accountability Office (GAO) released a 

report on clinical productivity and efficiency, which found that VA 

lacks complete and accurate information on provider productivity 


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7GAO–17–480, May 2017, ‘‘Improvements Needed in Data and Monitoring of Clinical Productivity and Efficiency,’’ https://www.gao.gov/assets/690/684869.pdf. 8 Ibid. 

9 Ibid. 

10 United States Cong. House Committee on Veterans’ Affairs. ‘‘Maximizing Access and Resources: An Examination of VA Productivity and Efficiency.’’ July 13, 2017. 115th Cong. 1st sess. 

Washington: GPO, 2017 (testimony of Randall B. Williamson, Director, Health Care, Government Accountability Office.). 11 VA Office of the Inspector General 18-01693-196, June 2018, ‘‘OIG Determination of Veterans Health Administration’s Occupational Staffing Shortages,’’ https://www.va.gov/oig/pubs/ 

VAOIG-18-01693-196.pdf. 12 Ibid. 13 Ibid. 14 Ibid. 

and efficiency.7 GAO also found that VA Central Office does not 

systematically oversee productivity and efficiency.8 As a result, VA 

cannot ensure that low productivity and clinical inefficiencies are 

addressed at individual VA medical facilities or identify and correct 

patterns that could increase productivity and efficiency across the 

VA health care system.9 In testimony regarding this report, GAO 

noted that, ‘‘[a]s VA’s funding levels increase, it is increasingly important that the Department spend these funds wisely and ensure 

that VA attains high levels of productivity among its clinical services and operational efficiency to maximize veterans’ access to care 

and minimize costs.’’ 10

In 2018, the IG released a report on staffing shortages, which 

found that physicians and nurses were the top two most commonly 

cited shortage occupations across the VA healthcare system.11 The 

Veterans Access, Choice, and Accountability Act of 2014 (Public 

Law 113–146; 128 STAT. 1754) first established the requirement 

for an annual IG report on VA staffing shortages. The report was 

then modified by the VA Choice and Quality Employment Act of 

2017 (Public Law 115–46; 131 STAT. 958). Since the first such report was released in 2014, the findings have remained largely consistent, with the largest clinical staffing shortages being physicians, nurses, psychologists, physician assistants, medical technologists, and physical therapists.12 To address these findings, the 

IG has recommended since 2015 that VA develop staffing models 

for critical occupations.13 The 2018 report notes that, ‘‘the [IG] has 

made recommendations related to the development and implementation of a staffing model in each of its previous staffing determination reports,’’ and, ‘‘re-emphasizes the need for VHA to develop and 

implement a robust and targeted staffing model.’’ 14

The Committee is concerned that, despite the significant amount 

of study and analysis and repeated recommendations for action, VA 

continues to struggle with medical facility staffing, productivity, 

and efficiency and continues to lack relevant models, tracking 

mechanisms, and plans to improve. Accordingly, section 1 of the 

bill would require VA to develop comprehensive staffing models for 

all VA medical centers, track RVUs for all providers, establish performance standards to evaluate clinical productivity and efficiency, 

develop remediation plans to address low clinical productivity and 

inefficiency, and ensure that providers who fall below minimum 

thresholds attend training on clinical procedure coding. The Committee recognizes that factors outside of an individual provider’s 

control—like insufficient exam room space or support staff—may 

negatively impact productivity and efficiency. The Committee also 

recognizes that some VA providers perform important and necVerDate Sep 11 2014 07:22 Nov 18, 2018 Jkt 089006 PO 00000 Frm 00004 Fmt 6659 Sfmt 6602 E:\HR\OC\HR1034.XXX HR1034

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15 July 11, 2018, Letter from Thelma Roach-Sherry BSN, RN, NE–BC., President, Nurses Organization of Veterans Affairs, to the Honorable David P. Roe, Chairman, Committee on Veterans’ Affairs, U.S. House of Representatives regarding H.R. 6066, as amended. 16 July 11, 2018. Letter from Thelma Roach-Sherry BSN, RN, NE–BC., President, Nurses Organization of Veterans Affairs, to the Honorable David P. Roe, Chairman, Committee on Veterans’ Affairs, U.S. House of Representatives regarding H.R. 6066, as amended. 

essary functions—like training and research—that may also impede productivity and efficiency. As such, section 1 of the bill would 

require VA to take non-clinical duties and productivity-limiting factors into account when developing performance standards and remediation plans. The Committee further recognizes that there may 

be non-RVU based measures and models that may be useful for VA 

to consider when implementing the requirements of this bill. In 

light of that, section 1 of the bill would also authorize VA to incorporate values-based productivity models. Feedback from stakeholder groups, including multiple veteran service organizations, 

was taken into account in the drafting of this bill and the Committee is grateful for their input. The Committee is also grateful 

for a letter provided by the Nurses Organization of Veterans Affairs (NOVA), which expressed support for an RVU-based system 

to capture and compare provider productivity and efficiency across 

the VA healthcare system, noted that VA already uses RVUs to 

track provider productivity in certain specialty services, and stated 

that that, ‘‘[b]y tracking these metrics, leadership would have a 

clearer picture of how resources are being used in each facility with 

the goal of providing effective and efficiency high-quality care.’’ 15

The Committee agrees with that assessment. NOVA also requested 

that, ‘‘consideration of any new requirement to address performance measures of providers take into account VA’s ‘whole health’ 

approach to care and the complex injuries of the veteran patients 

they serve.’’ 16 The Committee certainly expects that, in developing 

the performance standards and remediation plans that would be required by this bill, VA would account for the Department’s unique 

mission, needs, and initiatives. 

HEARINGS

On June 13, 2018, the Subcommittee on Health conducted a legislative hearing on a number of bills including H.R. 6066. 

The following witnesses testified: 

The Honorable Vicky Hartzler, U.S. House of Representatives, 4th District, Missouri; The Honorable Marcy Kaptur, 

U.S. House of Representatives, 9th District, Ohio; The Honorable Matt Cartwright, U.S. House of Representatives,17th District, Pennsylvania; The Honorable Clay Higgins, U.S. House 

of Representatives, 3rd District, Louisiana; The Honorable 

Mike Bost, U.S. House of Representatives, 12th District, Illinois; The Honorable Jeff Denham, U.S. House of Representatives, 10th District, California; The Honorable Jenniffer Gonzalez-Colon, U.S. House of Representatives, Puerto Rico; The 

Honorable Brad Wenstrup, U.S. House of Representatives, 2nd 

District, Ohio; Roscoe Butler, Deputy Director for Health Care, 

Veterans Affairs and Rehabilitation, The American Legion; 

Jeremy Villanueva, Associate National Legislative Director, 

Disabled American Veterans; Kayda Keleher, Associate Director, National Legislative Service, Veterans of Foreign Wars of 


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the United States; and Jessica Bonjorni MBA, PMP, SPHR, 

Acting Assistant Deputy Under Secretary for Health for Workforce Services, Veterans Health Administration, U.S. Department of Veterans Affairs, who was accompanied by Dayna Cooper MSN, RN, Director, Home and Community-Based Programs, Veterans Health Administration, U.S. Department of 

Veterans Affairs. 

Statements for the record were submitted by: 

American Orthotic and Prosthetic Association, Paralyzed 

Veterans of America, and Military Officers Association of 

America. 

SUBCOMMITTEE CONSIDERATION

On June 27, 2018, the Subcommittee on Health met in open 

markup session, a quorum being present and favorably forwarded 

H.R. 6066, as amended, to the Full Committee. During consideration of the bills, the following amendment was considered and 

agreed to by voice vote: 

An amendment in the nature of a substitute offered by Representative Neal Dunn of Florida, which would modify the performance standards and remediation plans as well as require 

VA to develop comprehensive staffing models for all VA medical centers. 

COMMITTEE CONSIDERATION

On July 12, 2018, the full Committee met in open markup session, a quorum being present, and ordered H.R. 6066, as amended, 

to be reported favorably to the House of Representatives by voice 

vote. During consideration of the bill, the following amendment 

was considered: 

An amendment in the nature of a substitute offered by Representative Ann Kuster of New Hampshire, which would—with 

the exception of the requirement for VA to develop comprehensive staffing models for VA medical centers—convert the bill to 

a three-year pilot program and impose numerous reporting requirements on VA and GAO. The amendment was not agreed 

to by voice vote. 

COMMITTEE VOTES

In compliance with clause 3(b) of rule XIII of the Rules of the 

House of Representatives, there were no recorded votes taken on 

amendments or in connection with ordering H.R. 6066, as amended, reported to the House. A motion by Representative Gus Bilirakis of Florida to report H.R. 6066, as amended, favorably to the 

House of Representatives was adopted by voice vote. 

COMMITTEE OVERSIGHT FINDINGS

In compliance with clause 3(c)(1) of rule XIII and clause (2)(b)(1) 

of rule X of the Rules of the House of Representatives, the Committee’s oversight findings and recommendations are reflected in the 

descriptive portions of this report. 


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STATEMENT OF GENERAL PERFORMANCE GOALS AND OBJECTIVES

In accordance with clause 3(c)(4) of rule XIII of the Rules of the 

House of Representatives, the Committee’s performance goals and 

objectives are to increase the productivity and efficiency of VA medical facilities in order to improve the accessibility and quality of 

care that VA provides to veteran patients. 

NEW BUDGET AUTHORITY, ENTITLEMENT AUTHORITY, AND TAX

EXPENDITURES

In compliance with clause 3(c)(2) of rule XIII of the Rules of the 

House of Representatives, the Committee adopts as its own the estimate of new budget authority, entitlement authority, or tax expenditures or revenues contained in the cost estimate prepared by 

the Director of the Congressional Budget Office pursuant to section 

402 of the Congressional Budget Act of 1974. 

EARMARKS AND TAX AND TARIFF BENEFITS

H.R. 6066, as amended, does not contain any Congressional earmarks, limited tax benefits, or limited tariff benefits as defined in 

clause 9 of rule XXI of the Rules of the House of Representatives. 

COMMITTEE COST ESTIMATE

The Committee adopts as its own the cost estimate on H.R. 6066, 

as amended, prepared by the Director of the Congressional Budget 

Office pursuant to section 402 of the Congressional Budget Act of 

1974. 

CONGRESSIONAL BUDGET OFFICE COST ESTIMATE

Pursuant to clause 3(c)(3) of rule XIII of the Rules of the House 

of Representatives, the following is the cost estimate for H.R. 6066, 

as amended, provided by the Director of the Congressional Budget 

Office pursuant to section 402 of the Congressional Budget Act of 

1974: 

U.S. CONGRESS, 

CONGRESSIONAL BUDGET OFFICE, 

Washington, DC, August 1, 2018. 

Hon. PHIL ROE, M.D., 

Chairman, Committee on Veterans’ Affairs, 

House of Representatives, Washington, DC. 

DEAR MR. CHAIRMAN: The Congressional Budget Office has prepared the enclosed cost estimate for H.R. 6066, a bill to amend title 

38, United States Code, to improve the productivity of the management of Department of Veterans Affairs health care, and for other 

purposes. 

If you wish further details on this estimate, we will be pleased 

to provide them. The CBO staff contact is Ann E. Futrell. 

Sincerely, 

KEITH HALL, 

Director. 

Enclosure. 


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H.R. 6066—A bill to amend title 38, United States Code, to improve 

the productivity of the management of Department of Veterans 

Affairs health care, and for other purposes 

Summary: H.R. 6066 would require the Department of Veterans 

Affairs (VA) to train certain medical staff to identify the level of resources used to provide medical services. CBO estimates that implementing the bill would cost $320 million over the 2019–2023 period, assuming appropriation of the necessary amounts. 

Enacting the bill would not affect direct spending or revenues; 

therefore, pay-as-you-go procedures do not apply. 

CBO estimates that enacting H.R. 6066 would not increase net 

direct spending or on-budget deficits in any of the four consecutive 

10-year periods beginning in 2029. 

H.R. 6066 contains no intergovernmental or private-sector mandates as defined in the Unfunded Mandates Reform Act (UMRA). 

Estimated Cost to the Federal Government: The estimated budgetary effect of H.R. 6066 is shown in the following table. The costs 

of the legislation fall within budget function 700 (veterans benefits 

and services). 

By fiscal year, in millions of dollars— 

2018 2019 2020 2021 2022 2023 2019– 

2023 

INCREASES IN SPENDING SUBJECT TO APPROPRIATION 

Estimated Authorization Level ..................................... 0 90 70 60 60 50 330 

Estimated Outlays ....................................................... 0 80 70 60 60 50 320 

Basis of estimate: For this estimate, CBO assumes that H.R. 

6066 will be enacted near the beginning of fiscal year 2019 and 

that the estimated amounts will be appropriated each year. Estimated outlays are based on historical spending patterns for the affected programs. 

The bill would require VA to train licensed independent providers (also known as LIPs, which include physicians, dentists, and 

nurses) who fail to meet certain standards for using relative-value 

units (RVUs) to evaluate medical services. RVUs are tools used by 

physicians participating in Medicare to rank on a common scale the 

resources (such as time, technical skill, and physical effort) used to 

provide various health care services. 

VA currently tracks RVUs for health care provided by the agency. Furthermore, the department is in the process of developing an 

internal website to offer voluntary training to its medical providers 

on using RVUs. However, according to VA, only 5 percent of the 

63,000 LIPs accurately document their medical services using 

RVUs. 

Using information from VA, CBO estimates that under the bill 

the department would train roughly 60,000 medical staff to use 

RVUs in 2019. We expect that training would be repeated annually 

until LIPs demonstrated sustained proficiency. On average, each 

LIP would require about three hours of training, which equates to 

a loss of about 540,000 clinical visits at an average cost of $145 per 

visit, CBO estimates. In order to continue the provision of health 

care, CBO expects VA would utilize community care to cover appointments while the LIPs are in training. Over time, CBO expects 

LIPs at VA would become increasingly proficient in using RVUs, 


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and would therefore require less training. On that basis, CBO estimates that providing training on using RVUs would cost $70 million in 2019 and $260 million over the 2019–2023 period. 

In addition, CBO expects VA would need to hire the equivalent of 140 full-time staff at an annual compensation rate of $80,000 

each to provide ongoing training and support at each medical facility. VA also would hire an additional staff member at VA’s central 

office at an annual compensation of $135,000 in 2019 for oversight. 

After factoring in inflation, CBO estimates that the increase in 

support staff would cost $10 million in 2019 and $60 million over 

the 2019–2023. CBO estimates minimal costs to prepare a one-time 

report and comprehensive staffing models within one year of enactment. 

In total, CBO estimates implementing H.R. 6066 would cost $320 

million over the 2019–2023 period. 

Pay-As-You-Go considerations: None. 

Increase in long-term direct spending and deficits: CBO estimates that enacting H.R. 6066 would not increase net direct spending or on-budget deficits in any of the four consecutive 10-year periods beginning in 2029. 

Mandates: H.R. 6066 contains no intergovernmental or privatesector mandates as defined in UMRA. 

Previous CBO Estimate: On February 15, 2018, CBO transmitted 

a cost estimate for H.R. 4242, the VA Care in the Community Act, 

as ordered reported by the House Committee on Veterans’ Affairs 

on December 19, 2017. H.R. 6066 is similar to section 205 of H.R. 

4242. CBO estimated that implementing section 205 of H.R. 4242 

would cost $9 million over 5 years for the direct costs of training 

and support. The estimated costs for implementing the similar requirements in this bill are higher, however, because new information from VA indicates that the department believes it would be required to spend more time and funding to train and support VA 

personnel on using RVUs. In addition, the department would 

outsource appointments while the VA personnel undergo training. 

Estimate prepared by: Federal costs: Ann E. Futrell; Mandates: 

Andrew Laughlin. 

Estimate reviewed by: Sarah Jennings, Chief, Defense, International Affairs, and Veterans’ Affairs Cost Estimates Unit; Leo 

Lex, Deputy Assistant Director for Budget Analysis. 

FEDERAL MANDATES STATEMENT

The Committee adopts as its own the estimate of Federal mandates regarding H.R. 6066, as amended, prepared by the Director 

of the Congressional Budget Office pursuant to section 423 of the 

Unfunded Mandates Reform Act. 

ADVISORY COMMITTEE STATEMENT

No advisory committees within the meaning of section 5(b) of the 

Federal Advisory Committee Act would be created by H.R. 6066, as 

amended. 

STATEMENT OF CONSTITUTIONAL AUTHORITY

Pursuant to Article I, section 8 of the United States Constitution, 

H.R. 6066, as amended, is authorized by Congress’ power to ‘‘proVerDate Sep 11 2014 07:22 Nov 18, 2018 Jkt 089006 PO 00000 Frm 00009 Fmt 6659 Sfmt 6602 E:\HR\OC\HR1034.XXX HR1034

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vide for the common Defense and general Welfare of the United 

States.’’ 

APPLICABILITY TO LEGISLATIVE BRANCH

The Committee finds that H.R. 6066, as amended, does not relate 

to the terms and conditions of employment or access to public services or accommodations within the meaning of section 102(b)(3) of 

the Congressional Accountability Act. 

STATEMENT ON DUPLICATION OF FEDERAL PROGRAMS

Pursuant to clause 3(c)(5) of rule XIII of the Rules of the House 

of Representatives, the Committee finds that no provision of H.R. 

6066, as amended, establishes or reauthorizes a program of the 

Federal Government known to be duplicative of another Federal 

program, a program that was included in any report from the Government Accountability Office to Congress pursuant to section 21 

of Public Law 111–139, or a program related to a program identified in the most recent Catalog of Federal Domestic Assistance. 

DISCLOSURE OF DIRECTED RULEMAKING

Pursuant to section 3(i) of H. Res. 5, 115th Cong. (2017), the 

Committee estimates that H.R. 6066, as amended, contains no directed rulemaking that would require the Secretary to prescribe 

regulations. 

SECTION-BY-SECTION ANALYSIS OF THE LEGISLATION

Section 1. Department of Veterans Affairs health care productivity 

improvement 

Section 1(a) of the bill would amend subchapter I of chapter 17 

of title 38 U.S.C. by inserting after section 1705A a new section 

‘‘§ 1705B. Management of health care; productivity’’. 

The new section 1705B(a) would require VA to track RVUs for 

all VA providers. 

The new section 1705B(b) would require VA to require VA providers to attend training on clinical procedure coding if the coding 

accuracy of the VA provider within their clinical area of responsibility falls below the minimum threshold set by VA. 

The new section 1705B(c) would require VA to establish, for each 

VA facility: standardized performance standards based on nationally recognized RVU production standards applicable to each specific professional in order to evaluate clinical productivity at the 

provider and facility level; remediation plans to address low clinical 

productivity and clinical inefficiency; and an ongoing process to systematically review the content, implementation, and outcome of 

such plans. In fulfilling these requirements, the new section 1705B 

would authorize VA to incorporate values-based productivity models and other productivity measures and models as determined appropriate by VA as well as require VA to take into account nonclinical duties, (including with respect to training and research), 

factors that impede productivity and efficiency, and actions plans 

to address such factors. 

The new section 1705B(d) would define ‘‘Department provider’’ to 

mean an employee of VA who has been appointed to the Veterans 


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Health Administration as a physician, dentist, optometrist, podiatrist, chiropractor, advanced practice registered nurse, or physician’s assistant acting as an independent provider and ‘‘relative 

value unit’’ to mean a unit for measuring workload by determining 

the time, mental effort and judgement, technical skill, physical effort, and stress involved in delivering a service. 

Section (b) of the bill would amend the table of contents at the 

beginning of chapter 17 of title 38 U.S.C. by inserting after the 

item relating to section 1705A the following new item: ‘‘§ 1705B. 

Management of health care; productivity.’’. 

Section (c) of the bill would require VA, not later than one year 

after the date of enactment of this Act, to submit to Congress a report on the implementation of the new section 1705B of title 38 

U.S.C. and require such report to include, for each professional category of VA providers, the RVU of each category at the national, 

regional, and facility levels. 

Section (d) of the bill would require VA, not later than one year 

after the date of enactment of this Act, to develop comprehensive 

staffing models for all VA medical centers. 

CHANGES IN EXISTING LAW MADE BY THE BILL, AS REPORTED

In compliance with clause 3(e) of rule XIII of the Rules of the 

House of Representatives, changes in existing law made by the bill, 

as reported, are shown as follows (existing law proposed to be omitted is enclosed in black brackets, new matter is printed in italic, 

and existing law in which no change is proposed is shown in 

roman): 

CHANGES IN EXISTING LAW MADE BY THE BILL, AS REPORTED

In compliance with clause 3(e) of rule XIII of the Rules of the 

House of Representatives, changes in existing law made by the bill, 

as reported, are shown as follows (new matter is printed in italic 

and existing law in which no change is proposed is shown in 

roman): 

TITLE 38, UNITED STATES CODE 

* * * * * * * 

PART II—GENERAL BENEFITS 

* * * * * * * 

CHAPTER 17—HOSPITAL, NURSING HOME, 

DOMICILIARY, AND MEDICAL CARE 

SUBCHAPTER I—GENERAL 

Sec. 

1701. Definitions. 

* * * * * * * 

1705A. Management of health care: information regarding health-plan contracts. 

1705B. Management of health care: productivity. 

* * * * * * * 


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SUBCHAPTER I—GENERAL 

* * * * * * * 

§ 1705B. Management of health care: productivity 

(a) RELATIVE VALUE UNIT TRACKING.—The Secretary shall track 

relative value units for all Department providers. 

(b) CLINICAL PROCEDURE CODING TRAINING.—If the coding accuracy of a Department provider within a clinical area of responsibility of the provider falls below the minimum threshold set by the 

Secretary, the Secretary shall require the Department provider to attend training on clinical procedure coding. 

(c) PERFORMANCE STANDARDS.—(1) The Secretary shall establish 

for each Department facility— 

(A) in accordance with paragraph (2), standardized performance standards based on nationally recognized relative value 

unit production standards applicable to each specific profession 

in order to evaluate clinical productivity at the provider and facility level; 

(B) remediation plans to address low clinical productivity 

and clinical inefficiency; and 

(C) an ongoing process to systematically review the content, 

implementation, and outcome of the plans developed under subparagraph (B). 

(2) In establishing the performance standards under paragraph 

(1)(A), the Secretary— 

(A) may incorporate values-based productivity models and 

may incorporate other productivity measures and models determined appropriate by the Secretary; and 

(B) shall take into account non-clinical duties, including with 

respect to training and research; 

(C) shall take into account factors that impede productivity 

and efficiency and, in developing remediation plans under 

paragraph (1)(B), shall incorporate action plans to address 

such factors. 

(d) DEFINITIONS.—In this section: 

(1) The term ‘‘Department provider’’ means an employee of the 

Department who has been appointed to the Veterans Health Administration as a physician, a dentist, an optometrist, a podiatrist, a chiropractor, an advanced practice registered nurse, or 

a physician’s assistant acting as an independent provider. 

(2) The term ‘‘relative value unit’’ means a unit for measuring 

workload by determining the time, mental effort and judgment, 

technical skill, physical effort, and stress involved in delivering 

a service. 

* * * * * * * 


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1 United States Cong. House Committee on Veterans’ Affairs, Subcommittee on Health Oversight Hearing—‘‘Clinical Productivity and Efficiency in the Department of Veterans’’ Affairs 

Healthcare System.’’ July 13, 2017. 115th Cong. 1st sess. Washington: GPO, 2017 (statement 

from Carolyn Clancy, M.D., Deputy Under Secretary for Organizational Excellence at the Veterans Health Administration of the Department of Veterans’ Affairs). 

MINORITY VIEWS 

As written, the Minority has serious concerns with H.R. 6066. In 

particular, we are concerned the implementation of this measure 

on a permanent basis will erode the unique the patient-provider relationship within the Department of Veterans’ Affairs (VA). In addition, this measure could also lead Congress to misinterpret VA’s 

budgetary needs and workload as it considers appropriations measures in the coming years. 

Not only is the measure superfluous in its call for collection of 

RVUs, but redundant as VHA has collected and reported back to 

facilities on clinical productivity metrics since 2013. By utilizing 

the Specialty Productivity-Access Report and Quadrant (SPARQ) 

tool, VHA ‘‘measures specialty physician value in the form of ‘‘compensation per RVU’’ so as to demonstrate [its] ability to be good 

stewards of public healthcare resources.’’ 1

While we agree with the Majority that increasing provider productivity at VA should be addressed in order to ensure VHA remains a leader in the delivery of veterans’ health care, we are 

alarmed this provision could have unintended consequences as we 

move forward. For this reason, we must align ourselves with the 

concerns expressed by a variety of witnesses in regard to the measure including VA and Veterans Service Organizations (VSOs). 

On July 13, 2017, the Members of the Subcommittee on Health 

heard from several witnesses, including representatives from the 

Government Accountability Office (GAO) and VA, that each indicated the capture of traditional RVUs at VA would not provide the 

most accurate reflection of provider productivity for several reasons. Chief among these is attempting to compare RVUs at VA 

with the private sector. 

As witnesses stated, this is problematic because the comparison 

is not apples-to-apples. Instead it is more akin to apples-to-oranges. 

Witnesses pointed out (1) VA providers have limited space with a 

provider-to-office ratio of 1:1 whereas private industry is 1:3 or 4 

even; and (2) veteran care is more time consuming as veterans tend 

to list a litany of ailments during a Primary Care Provider visit 

due to their likelihood of having multiple comorbidities; whereas civilians tend to experience one health issue at a time. 

While the measure at hand does not call for an explicit comparison of VA to private sector RVUs, the capture and public reporting 

to Congress on this data would provide opponents of VA with fodder to further misrepresent VA’s capacity to deliver quality 

healthcare. By taking the data produced as a result of this measure 


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2 Comparing Quality of Care in Veterans Affairs and Non-Veterans Affairs Settings, https:// 

www.rand.org/pubs/external_publications/EP67588.html. 3 United States Cong. House Committee on Veterans’ Affairs, Subcommittee on Health Oversight Hearing—‘‘Clinical Productivity and Efficiency in the Department of Veterans’’ Affairs 

Healthcare System.’’ July 13, 2017. 115th Cong. 1st sess. Washington: GPO, 2017 (statement 

from Carolyn Clancy, M.D., Deputy Under Secretary for Organizational Excellence at the Veterans Health Administration of the Department of Veterans’ Affairs). 4 Id. 

and comparing it to various private sector facilities, opponents of 

VA could argue that taxpayer’s money would be better spent in the 

community. However, the services provided by VA when compared 

to the private sector are more comprehensive, time consuming, and 

of a higher quality.2 The Minority is not confident this data would 

be published in a responsible manner that would lead to an increase in VA productivity. 

In addition, the implementation of this measure system-wide 

would threaten the integrity of VHA’s currently data architecture, 

the Veterans Information Systems and Technology Architecture 

(VistA). In July 2017, VA testified that VistA ‘‘was never designed 

to capture data related to billing type, so a variety of complex 

workarounds are needed to assemble an approximation of RVUs. 

These workarounds introduce a risk of reporting inaccurate numbers; and we magnify that risk by expanding the scope of measurement.’’ 3

However, in May 2018, VA officially signed a contract to modernize VHA’s electronic health record system by adopting a system 

similar to that of the Department of Defense’s. Among other advancements, the new electronic health records system is expected 

to be ‘‘better configured for workload capture and billing using private-sector standards, and could help embed workflow indicators 

that transparently capture data regarding productivity and minimize inaccuracies due to our current workarounds.’’ 4

Given all of these concerns, the Minority offered an alternative 

at markup which would have created a three-year pilot program to 

be carried out at 15 medical facilities in which VHA tracks the relative value units of health care providers. Much like H.R. 6066, the 

Secretary would be required to provide additional training to providers falling below an average level of productivity and would be 

required to establish performance standards for each medical facility. Additionally, it called on VA to submit a well-rounded implementation plan, quarterly reports and a final report on whether it 

was feasible and advisable to extend the program. GAO would be 

required to assess both the implementation plan and final report 

within 60 days of its submission. Unfortunately, it was not adopted. 


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The Committee is in agreement that the productivity of 

healthcare providers employed by the Department of Veterans’ Affairs should increase in accord with budgetary increases, the minority is not convinced that the tracking of RVUs will produce reliable information upon which veteran-patients and Congressional 

appropriators should base their decisions. 

MARK TAKANO, 

Vice Ranking Member. 

Æ 


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