```

[House Report 115-1034]
[From the U.S. Government Publishing Office]

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
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:

``Sec. 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 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 
well-staffed 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\
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
    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\
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
    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 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\
---------------------------------------------------------------------------
    \7\GAO-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.).
---------------------------------------------------------------------------
    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\
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
    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 necessary 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.
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------

                                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 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.

         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.

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, 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 
private-sector 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 ``provide 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 ``Sec. 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 
non-clinical 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 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: ``Sec. 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

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PART II--GENERAL BENEFITS

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   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.
     * * * * * * *

SUBCHAPTER I--GENERAL

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Sec. 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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                             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\
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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).
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    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 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.
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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.
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    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\
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    \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).
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    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\
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    \4\Id.
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    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.
    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.

                                  [all]
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