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41–911 PDF 2008

S. HRG. 110–377

OVERSIGHT HEARING: HIRING PRACTICES AND

QUALITY CONTROL IN VA MEDICAL FACILITIES

HEARING

BEFORE THE

COMMITTEE ON VETERANS’ AFFAIRS 

UNITED STATES SENATE

ONE HUNDRED TENTH CONGRESS

FIRST SESSION

NOVEMBER 6, 2007

Printed for the use of the Committee on Veterans’ Affairs

(

Available via the World Wide Web: http://www.access.gpo.gov/congress/senate 

(II)

COMMITTEE ON VETERANS’ AFFAIRS 

DANIEL K. AKAKA, Hawaii, Chairman 

JOHN D. ROCKEFELLER IV, West Virginia 

PATTY MURRAY, Washington 

BARACK OBAMA, Illinois 

BERNARD SANDERS, (I) Vermont 

SHERROD BROWN, Ohio 

JIM WEBB, Virginia 

JON TESTER, Montana 

RICHARD M. BURR, North Carolina, Ranking 

Member 

ARLEN SPECTER, Pennsylvania 

LARRY E. CRAIG, Idaho, 

JOHNNY ISAKSON, Georgia 

LINDSEY O. GRAHAM, South Carolina 

KAY BAILEY HUTCHISON, Texas 

JOHN ENSIGN, Nevada 

WILLIAM E. BREW, Staff Director 

LUPE WISSEL, Republican Staff Director 

(III)

C O N T E N T S 

NOVEMBER 6, 2007

SENATORS 

Page 

Akaka, Hon. Daniel K., Chairman, U.S. Senator from Hawaii ........................... 1

Burr, Hon. Richard M., Ranking Member, U.S. Senator from North Carolina .. 2

Durbin, Hon. Richard J., U.S. Senator from Illinois ............................................ 3

Murray, Hon. Patty, U.S. Senator from Washington ........................................... 5

WITNESSES 

Cross, Gerald M., M.D., Principal Deputy Under Secretary for Health, U.S. 

Department of Veterans Affairs; accompanied by Peter Almenoff, M.D., 

Director, Veterans Integrated Service Network 15; Dr. George O. Maish, 

Jr., Chief of Surgery, Lenanon, Pennsylvania, VA Medical Center; and 

Kathryn Enchelmayer, Director of Quality Standards, Veterans Health Administration .......................................................................................................... 6

Prepared statement .......................................................................................... 8

Williamson, Randall B., Acting Director, Health Care, U.S. Government Accountability Office ................................................................................................ 21

Prepared statement .......................................................................................... 22

Duckworth, Tammy, Director, Illinois Department of Veterans’ Affairs ............ 38

Prepared statement .......................................................................................... 39

McCarthy, Steven, Veteran, Operation Iraqi Freedom ........................................ 42

Prepared statement .......................................................................................... 44

APPENDIX 

American Academy of Physician Assistants; prepared statement ....................... 51

(1)

OVERSIGHT HEARING: HIRING PRACTICES 

AND QUALITY CONTROL IN VA MEDICAL 

FACILITIES 

TUESDAY, NOVEMBER 6, 2007

U.S. SENATE, 

COMMITTEE ON VETERANS’ AFFAIRS, 

Washington, D.C. 

The Committee met, pursuant to notice, at 9:34 a.m., in room 

SD–562, Dirksen Senate Office Building, Hon. Daniel K. Akaka, 

Chairman of the Committee, presiding. 

Present: Senators Akaka, Murray, Durbin and Burr 

OPENING STATEMENT OF HON. DANIEL K. AKAKA, CHAIRMAN, 

U.S. SENATOR FROM HAWAII 

Senator AKAKA. This hearing will come to order. This morning’s 

hearing will focus on hiring practices and quality controls in VA 

hospitals and clinics. Among the issues we will address are the recent events at the Marion, Illinois, VA Medical Center. VA’s internal tracking found a sharp and disturbing increase in the number 

of deaths at that hospital. In addition, they found cases of serious 

and unexpected complications from routine surgeries performed 

there. 

As Chairman of the Senate Committee on Veterans’ Affairs, it is 

very important to me that all veterans get the best possible care 

from the best possible health care practitioners. To achieve that 

goal, we must ensure that all providers are appropriately checked 

for their credentials and privileges. 

I note that the Inspector General’s office is in the midst of an investigation about the personnel involved in those events at the 

Marion VA, and because of this the IG will not be testifying today. 

Knowing of Senator Durbin’s interest, and with Senator Burr’s 

concurrence, I have asked Senator Durbin to join us on the dais for 

this hearing. While this issue was brought to my attention due to 

the troubling situation at the Marion VA, it may indeed have implications for the entire VA health care system and the more than 

140,000 providers employed by VA. 

When the IG’s investigation is complete, the Committee will review that report to ensure that no structural problems exist in VA’s 

process to appropriately screen its employees. If systemic problems 

are found, we will work to address them. 

I want to thank you all for being here, and we look forward to 

the testimony of our witnesses. 

2

At this time I would like to call on our Ranking Member for his 

comments, and then we will turn to Senator Durbin. 

STATEMENT OF HON. RICHARD M. BURR, RANKING MEMBER,

U.S. SENATOR FROM NORTH CAROLINA 

Senator BURR. Thank you, Mr. Chairman. I appreciate you calling this hearing to look into what I think are extremely important 

matters. I would like the record to note that I know that there is 

interest on the part of Senator Durbin and Senator Obama, and 

were this North Carolina, I would have the same interest, and I 

am sure Senator Murray would for Washington. And as Committee 

Members, it is our responsibility to look into this. I asked the 

Chairman, though, not to hold this hearing because I think it is 

premature and inappropriate when there is a current investigation 

going on to believe that we can get to the bottom of the problem 

and that, in fact, we might—and I stress the word ‘‘might’’—encumber the IG’s investigation by what might be said, what might 

be reported, or what might be asked. 

So, I reluctantly am here today. I understand the need of the 

State’s Senators to be in front of this issue, and I respect the fact 

that both of them have been very vocal on it. And it is my understanding that the VA is currently in the process of sending a team 

in to look at multidisciplinary assessments of the entire Marion facility. 

We do owe our veterans not only the very best medical care but 

also the highest quality professionals that we can put there to deliver that care. One way to show our commitment to our veterans 

is to ensure that the VA’s hiring practices conform to the highest 

standards possible. However, these recent allegations of substandard care at the Marion VA Medical Center have called into 

question the VA’s current system for credentialing and privileging 

health care professionals. 

Everyone in the veterans community—including those who care 

for veterans professionally, concerned family members, and veterans themselves—was alarmed when they learned of the sharp 

rise in deaths at Marion. These deaths have raised many questions 

about whether substandard care and poor hiring practices are to 

blame. 

As you pointed out, Mr. Chairman, the VA Inspector General is 

in the midst of an investigation into the deaths at the Marion VA 

facility, which is why he declined to testify at today’s hearing, and 

I am glad he did decline. I have spoken to the Inspector General. 

He has assured me this is an active, ongoing investigation, and 

that when that investigation is complete, he intends to fully brief 

this Committee and to make himself available for any requests for 

hearings. 

Mr. Chairman, I would suggest today, rather than jump to conclusions about what did or did not happen, or what may or may 

not be wrong with VA credentialing, that we wait until the IG has 

done his work. Let him investigate these issues and report back his 

findings. At that time, we will be better able to answer questions 

such as: Was the VA credentialing or privileging process itself at 

fault? Was the Marion facility negligent in following the estabVerDate 0ct 09 2002 14:37 May 20, 2008 Jkt 000000 PO 00000 Frm 00006 Fmt 6633 Sfmt 6633 H:\PS41451\DOCS\41911.TXT SENVETS PsN: PAULIN
3

lished VA process? And what exactly happened at Marion and, 

more importantly, who is responsible? 

Mr. Chairman, we owe it to the surviving families to get to the 

bottom of the Marion case. We also owe it to our veterans to find 

out whether the rise in deaths at Marion is a warning sign of a 

system-wide credentialing and privileging problem within the VA. 

Mr. Chairman, I know we both share a desire to see that these 

issues are thoroughly investigated. Once the IG’s work is complete, 

I hope you will be calling a hearing, one where we can call the appropriate witnesses—not that those who are here today are not 

welcomed, but that we can look at the facts and ask the hard questions but, more importantly, get the right answers as it relates to 

the Marion VA facility. 

So, Mr. Chairman, again, I thank you for the opportunity to be 

here. I welcome my colleagues, Senator Durbin and Senator Murray, and I am sure that if, in fact, there is some information to 

glean today, we will glean that. 

Senator AKAKA. Thank you, Senator Burr. 

Senator Durbin? 

STATEMENT OF HON. RICHARD J. DURBIN,

U.S. SENATOR FROM ILLINOIS 

Senator DURBIN. Mr. Chairman, thank you very much, and, Senator Burr, thank you for agreeing to this hearing. And I would like 

to say at the outset that Senator Obama and I have been involved 

in this from the start. Although he is not here this morning, he certainly shares my concern about what has happened at the Marion 

VA Hospital. 

Let me say at the outset that the Marion VA Medical Center has 

served veterans in our region for generations, with extraordinarily 

good professional care. It enjoys a great reputation in southern Illinois, Indiana, and Kentucky for providing that care for veterans 

who have served us so honorably in many places around the world. 

And that is why this current situation is so troubling. 

Let me concur with Senator Burr. We will not know the details 

on what happened here until the inspection is complete. There are, 

in fact, two inspections underway—one by the Inspector General’s 

office and the other, I am told, by the quality assurance team at 

the Veterans Administration. And I welcome their conclusions, and 

I hope they are presented thoroughly and very soon. 

But there are some things that we do know that are indisputable, and the information I am about to relate has been related 

directly to me by the Veterans Administration and I think is the 

reason why we can meet today and talk about some of the larger 

issues that this presents. 

We know that in August of this year, it came to the attention of 

the Veterans Administration that there was a dramatic increase in 

surgical deaths at the Marion VA Medical Center, so much so that 

investigative teams were sent quickly and determined to give administrative leave to four of the top administrators at this Marion 

hospital. Shortly thereafter, a surgeon resigned—Dr. Mendez—and 

surgical activities were severely curtailed at the Marion hospital. 

That continues to this day while the investigation is underway. 

4

There have been serious questions raised about the credentialing 

of the doctor who resigned, and I think that is what has given rise 

to our need for this hearing. This doctor was licensed in the State 

of Massachusetts and in the State of Illinois when he came on the 

staff of the Marion VA Medical Center. And it was after that time, 

about a year after, maybe a year and a half after he came on at 

the Marion VA Medical Center, that he surrendered his license in 

the State of Massachusetts to practice medicine, and it was characterized as for ‘‘nondisciplinary reasons.’’ When he was asked why 

he would surrender his license to practice, he indicated he did not 

plan on returning to Massachusetts and he did not want to continue to pay the fees that were involved. I think those facts are 

basic and not much dispute about them. 

We have come to learn that before he was hired by the Marion 

VA Hospital, he had two malpractice cases filed against him in the 

State of Massachusetts and one disciplinary action by a hospital. 

The question that I think this raises is: What is due diligence? 

What should the VA use as their standard to determine whether 

a doctor is fit and competent to practice at a Marion VA medical 

facility or any VA medical facility? 

There are serious questions that have been raised here about the 

level of communication, for example, between the State of Massachusetts and the VA medical system in general and Marion VA in 

particular. As I understand it, a person can practice at a VA facility without being licensed in the State where that VA facility exists. And so, obviously, there is a need for communication with 

other States and other licensure boards to find out whether anything extraordinary has happened. 

Since this investigation is underway, it has been publicly reported that another doctor has been suspended at the Marion VA 

Medical Center for his failure to disclose that he was licensed in 

another State. The reason that is important, of course, is that we 

want to keep on top of that situation to see if there have been any 

problems with that licensure in the other State. 

Well, under the circumstances here, there are a lot of questions 

that need to be asked and answered about the policies of 

credentialing medical professionals who come into the VA medical 

system. I have been told that there are some 15,000 to 18,000 doctors in the system at this time. So, clearly, this is a major responsibility and undertaking by the VA. 

The one point I would like to make to Senator Burr—and I hope 

he will understand and appreciate—is that I asked Members of my 

staff to go down to Marion and to talk to some of the people who 

were there. They have established a line of communication with a 

number of people who are participating in the investigation, as 

they should, and I encourage them to. But the sad reality is that 

at least three or four people with significant information in important positions at the Marion VA Medical Center have communicated to my office that they are unwilling to come forward, and 

they do not want to give this information for fear of reprisal and 

for fear of being terminated. 

Now, let me say in conclusion here a word about Acting VA Secretary Gordon Mansfield. I did not know the man until we got involved in this issue. He has come by my office, and we have spoken 

5

on the phone several times. I do not think we could ask for a better 

person to be head of the Veterans Administration. Mr. Mansfield 

is a veteran of Vietnam. He still carries the wounds from those battles. And I am convinced, I am personally convinced, that he is 

dedicated to the veterans in our country above everything else. His 

responses to me throughout have been clear and unequivocal. He 

wants to know what happened here. He wants to get to the truth, 

and he wants to protect those who will come forward in an honest 

fashion to tell what happened. He has said that to me repeatedly 

and said it again this morning. He told me that he is sending a 

special team now from the Veterans Administration to Marion to 

try to establish a better line of communication here. 

We really need to get all the information and facts in, and, Senator Burr, I hope that this hearing, which will be reported, I am 

sure, back in Illinois, will be an indication to those employees to 

cooperate in good faith with the investigation, to feel that they can 

come forward and tell what happened honestly in this circumstance 

and get to the truth of it. 

In the meantime, I hope this hearing will help us understand the 

process that is being followed to make certain that this never happens again and that we do everything we can to make sure that 

people in the VA medical system, the medical professionals, are 

skilled and competent. 

Thank you. 

Senator AKAKA. Thank you. 

Senator Murray? 

STATEMENT OF HON. PATTY MURRAY,

U.S. SENATOR FROM WASHINGTON 

Senator MURRAY. Thank you very much, Mr. Chairman and Senator Burr, for holding today’s important hearing on the tragic 

events that happened in Marion. Even with all of the controversy 

that is going on with the Department of Veterans Affairs within 

the context of this conflict, I know and I believe that overall our 

physicians and our clinical staff at the VA provide excellent care 

for our veterans. We hear it everywhere we go. The VA health care 

system has been an innovator in clinical care, in research in areas 

like PTSD and trauma care and electronic medical records, and 

they boast some of the most talented, knowledgeable physicians 

and staff in the country. So it was for that reason that I was deeply 

concerned when I heard about the physician at the Marion VA that 

was responsible apparently for providing care to our veterans that 

may have put them in danger. 

So I hope that today’s hearing, Mr. Chairman, is an opportunity 

to look at the procedures that are in place in the VA in terms of 

screening physicians and clinical staff so that we know the best 

procedures are in place so that an incident like this will not occur. 

And I think it is important that we ask the question of whether 

or not this was an isolated event or whether we have a systemwide issue. We want to know how common these problems are or 

possibly could be within the system. And I would like to know what 

the process is that the VA does have for screening health care providers as we are in the process right now of hiring a number of new 

physicians as we are putting a lot more resources, importantly, as 

6

we should be—into the VA today and, importantly, how we can prevent a tragedy like this from ever occurring again. 

So I think today’s hearing is extremely important. I think the 

men and women in uniform who serve us very proudly have a right 

to know that we are doing due diligence to make sure that the care 

that they get is the best possible, that we have safe and effective 

care for them. That is the highest quality care available. 

So I appreciate the opportunity to have this hearing today, and 

I look forward to hearing from all of our witnesses so that we can 

learn from the tragedy that has occurred. 

Thank you. 

Senator AKAKA. Thank you. Thank you very much, Senator Murray. 

I want to welcome the first panel, from the Department of Veterans Affairs, Dr. Gerald M. Cross, Principal Deputy Under Secretary for Health. He is accompanied by Dr. Peter Almenoff, Director of the VA Heartland Network; and Dr. George O. Maish, Jr., 

Chief of Surgery at the Lebanon, Pennsylvania, VA Medical Center; 

and Kate Enchelmayer, Director of Quality Standards for the Veterans Health Administration. I want to thank you all for being 

here today, and as I mentioned in my opening statement, we are 

focusing on hiring practice as well as quality controls in VA hospitals and clinics. And, of course, what has happened in the Marion 

event also plays in this, and we are looking at credentials of the 

medical professionals. 

And, with that, Dr. Cross, will you please begin? 

STATEMENT OF GERALD M. CROSS, M.D., PRINCIPAL DEPUTY 

UNDER SECRETARY FOR HEALTH, U.S. DEPARTMENT OF 

VETERANS AFFAIRS; ACCOMPANIED BY PETER ALMENOFF, 

M.D., DIRECTOR, VETERANS INTEGRATED SERVICE NETWORK 15; GEORGE O. MAISH, JR., M.D., CHIEF OF SURGERY, 

LEBANON, PENNSYLVANIA, VA MEDICAL CENTER; AND 

KATHRYN ENCHELMAYER, DIRECTOR, QUALITY STANDARDS, VETERANS HEALTH ADMINISTRATION 

Dr. CROSS. Good morning, Mr. Chairman and Members of the 

Committee. Thank you for the opportunity to come here today to 

discuss VA’s Credentialing and Privileging and its impact on current events at the Marion VA health care facility. I am accompanied by Ms. Kate Enchelmayer, our Director of Quality Standards, to my right; Dr. Peter Almenoff, at the end of the desk, the 

Director of Veterans Integrated Service Network 15; and Dr. 

George Maish, Jr., Chief of Surgery, Lebanon, Pennsylvania, VA 

Medical Center. 

My testimony will summarize our extensive credentialing and 

privileging process. I will also describe the National Surgery Quality Improvement Program, now famously known as NSQIP, that 

prompted our investigation at Marion. 

Before I begin, please be assured that my foremost priority, VA’s 

foremost priority, is the care and well-being of our patients, our 

veterans. That priority is what led us to take swift action at the 

Marion VA facility.Credentialing: Credentials are a person’s educational, training, experience, current competence, health status, 

certification, and licensure documents. VA’s standardized electronic 

7

credentialing program, called ‘‘VetPro,’’ is used system-wide to document the credentials of health care providers. VA realizes that accurate credentialing is a cornerstone to ensuring qualified health 

care providers are hired and, in addition to the credentialing done 

on every licensed provider, the process of privileging that provider 

to administer care within the scope of his license and clinical competence and within the medical center’s supporting capability remains an essential part of the initial processing that must be completed before the provider begins his duties within the VA. This 

process is completed on initial appointment and at a minimum of 

every 2 years thereafter, before transfer from another medical facility, or whenever the provider requests an addition to his or her 

privileges. 

The credentialing officer at a medical center obtains primary 

source information on all credentials. This is accomplished by direct contact with the source providing the education, training, certification, licensure, or registration. Information submitted by an 

individual health care practitioner is verified at that source. This 

includes confirming the practitioner’s answers to 17supplemental—

sometimes called ‘‘attestation’’—questions specific to denial, surrender, revocation, and termination of a credential, privileges, and 

medical society affiliation, as well as any convictions. If a provider’s 

license required for the position within VHA has ever been revoked 

or surrendered for cause—that is, for reasons of substandard care, 

professional misconduct, or professional incompetence—that provider is not eligible for employment in VHA unless that license has 

been fully restored. All practitioners must possess at least one full, 

active, current, and unrestricted license to practice. 

In addition, VA uses other flagging systems during the 

credentialing process and the determination of suitability for employment. These include, but are not limited to, the National Practitioner Data Bank-Health Integrity and Protection Data Bank, 

and the Disciplinary Alerts Service of the Federation of State Medical Boards. Moreover, VA continuously monitors physician licensure for any disciplinary or untoward activity with the FSMB. VA 

also queries a database maintained by the Office of the Inspector 

General at the Department of Health and Human Services that 

lists all individuals and entities that are currently excluded from 

participation in Medicare, Medicaid, and all other Federal health 

care programs. 

VA also uses the background investigation that is generally required on all new Federal employees. It consists of a National 

Agency Check, the Defense Clearance and Investigations Index, the 

FBI Identification Division’s name and fingerprint files; as well as 

written inquiries and searches of records covering specific areas of 

a person’s background during the past 5 years. Those inquiries are 

sent to current and past employers, schools attended, references, 

and local law enforcement authorities. 

Now to clinical privileging. In VA, health care providers licensed 

for independent practice are given ‘‘privileges’’ that cover the 

breadth of their area of clinical practice. Specifically, these privileges are permissions to perform the individual procedure(s). These 

requested procedures are recommended by the executive committee 

of the medical staff and approved by the medical center director in 

8

accordance with medical center bylaws. Clinical privileges are focused on provider clinical practice and are medical center-specific, 

provider-specific, and within the scope of the provider’s licensure, 

training, experience and competency, medical/clinical knowledge, 

and the provider’s health. Consideration is also given to any information related to medical malpractice allegations or judgments, 

loss of medical staff membership, and loss of clinical privileges. 

Clinical privileges are granted for a period not to exceed 2 years 

at which time they must be re-evaluated and reissued. The service 

chief assesses updated information that mirrors items reviewed at 

the provider’s initial appointment. The service chief then recommends which privileges should be granted or re-granted to the 

executive committee of the medical staff which is chaired by the 

medical center chief of staff. The executive committee evaluates the 

materials to determine if medical and clinical knowledge and clinical competence are adequately demonstrated to support recredentialing and the granting of the requested privileges. A final 

recommendation is then submitted to the medical center director 

who is the authority to grant privileges. 

Now I want to mention NSQIP. NSQIP is that program that 

gathers aggregate data from surgical outcomes to determine whether there are significant deviations in mortality or morbidity rates 

for major surgical procedures. Since the beginning of fiscal year 

2007, this information is reported on a quarterly basis. Prior to 

that time, the information had been gathered yearly. It was decided that NSQIP would be a better tool if the data were gathered 

more frequently. This was reinforced when our NSQIP data was 

evaluated after the onset of the new timing. 

In response to an elevated ratio of expected surgical deaths during the first two quarters of fiscal year 2007, we, the VA, sent a 

NSQIP team to conduct an onsite visit at the Marion, Illinois, VA 

Medical Center. This was conducted as part——

Senator AKAKA. Dr. Cross, will you please summarize your statement? 

Dr. CROSS. In conclusion, Mr. Chairman, VA has multiple tools 

in place for assessing and evaluating health care, and they are 

working, as in this case, to identify any irregularities and to correct 

them. These tools are part of the ongoing processes that are used 

to not only reveal the positive but also the vulnerabilities and deficiencies. We acknowledge these findings and seek to actively address the challenges they present. Moreover, the lessons learned 

are disseminated to health care providers throughout our health 

care system. 

Thank you, sir. 

[The prepared statement of Dr. Cross follows:]

PREPARED STATEMENT OF DR. GERALD CROSS, PRINCIPAL DEPUTY UNDER SECRETARY

FOR HEALTH, DEPARTMENT OF VETERANS AFFAIRS

Good morning, Mr. Chairman and Members of the Committee. Thank you for the 

opportunity to come here today to discuss VA’s Credentialing and Privileging and 

its impact on current events at the Marion VA health care facility. I am accompanied by Ms. Kate Enchelmayer, our Director of Quality Standards, Dr. Peter 

Almenoff, Director of Veterans Integrated Service Network 15, and Dr. George 

Maish, Chief of Surgery, Lebanon, Pennsylvania, VA Medical Center.

9

CREDENTIALING

Credentials are a person’s educational, training, experience, current competence, 

health status, certification and licensure documents. The Department of Veterans 

Affairs’ (VA) standardized electronic credentialing program, VetPro, is used systemwide to document the credentials of health care providers. VA realizes that accurate 

credentialing is a cornerstone to ensuring qualified health care providers come into 

the system. In addition to the credentialing done on every licensed provider, the 

process of privileging that provider to administer care within the scope of his license 

and clinical competence and within the medical center’s supporting capability remains an essential part of the initial processing that must be completed before the 

provider begins his duties within the Veterans Health Administration (VHA). This 

process is completed on initial appointment and at a minimum of every 2 years 

thereafter, before transfer from another medical facility, or whenever the provider 

requests an addition to his privileges. 

The Credentialing Officer at a medical center obtains primary source information 

on all credentials. This is accomplished by direct contact with the entity providing 

the education, training, certification, licensure or registration. Information submitted by an individual health care practitioner is verified with that entity. This 

includes confirming the practitioner’s answers to 17 supplemental/attestation questions specific to denial, surrender, revocation and termination of a credential, privileges, and medical society affiliation, as well as felony charges and any convictions. 

If a provider’s license required for the position within VHA has ever been revoked 

or surrendered for cause (i.e., for reasons of substandard care, professional misconduct, or professional incompetence), that provider is not eligible for employment 

in VHA unless that license has been fully restored. The practitioner also is required 

to possess at least one full, active, current, and unrestricted license to practice. 

In addition, VA uses other flagging systems during the credentialing process and 

the determination of suitability for employment. These include the National Practitioner Data Bank—Health Integrity and Protection Bank (NPDB–HIPDB), the Disciplinary Alerts Service of the Federation of State Medical Board (FSMB), the 

Health and Human Services Office of Inspector General List of Excluded Individuals 

and Entities (LEIE), the National Agency Check and Inquiry (NACI), and the Special Agreement Check (SAC) (fingerprint check). The NPDB is queried for reports 

of malpractice payments or adverse actions against clinical privileges by another entity. The HIPDB, which is a national data collection program for the reporting and 

disclosure of certain final adverse actions taken against health care practitioners, 

providers, and suppliers, is queried. Moreover, VA continuously monitors physician 

licensure for any disciplinary or untoward activity with the FSMB. VA also queries 

the LEIE, which is a database maintained by the Office of the Inspector General 

at the Department of Health and Human Services that lists all individuals and entities that are currently excluded from participation in Medicare, Medicaid and all 

other Federal health care programs. 

The NACI is the basic and minimum background investigation generally required 

on all new Federal employees. It consists of a National Agency Check (NAC) of 

OPM’s Security/Suitability Investigations Index (SII); the Defense Clearance and Investigations Index (DCII); the FBI Identification Division’s name and fingerprint 

files; as well as written inquiries and searches of records covering specific areas of 

a person’s background during the past 5 years. Those inquiries are sent to current 

and past employers, schools attended, references, and local law enforcement authorities. 

Providers as well as all applicants are subject to a pre-employment background 

investigation. The SAC, an OPM investigation tool is a fingerprint based criminal 

history check that is processed through the FBI.

CLINICAL PRIVILEGING (PRIVILEGES)

In VA, a health care provider licensed for independent practice is given ‘‘privileges’’ that cover the breadth of their area of clinical practice. Specifically, these 

privileges are permissions to perform the individual procedure(s). These requested 

procedures are recommended by the executive committee of the medical staff and 

approved by the medical center director in accordance with medical center bylaws. 

Clinical privileges are focused on provider clinical practice and are medical centerspecific, provider-specific, and within the scope of the provider’s licensure, training, 

experience and competency, medical/clinical knowledge and provider health status 

(as it relates to the individual’s ability to perform the requested clinical privileges). 

Consideration is also given to any information related to medical malpractice allegaVerDate 0ct 09 2002 14:37 May 20, 2008 Jkt 000000 PO 00000 Frm 00013 Fmt 6633 Sfmt 6621 H:\PS41451\DOCS\41911.TXT SENVETS PsN: PAULIN
10

tions or judgments, loss of medical staff membership, and loss or reduction in clinical privileges. 

Clinical privileges are granted for a period not to exceed 2 years at which time 

they must be re-evaluated and reissued. Re-privileging begins with the licensed 

health care provider applying through VetPro, updating all credentials/certification 

information, provision of peer references, and, again, answering the 17 supplemental/attestation questions. The service chief assesses updated information that 

mirrors items reviewed for the provider’s initial appointment. The service chief, 

along with the credentialing officer, then recommends which privileges should be 

granted/re-granted to the executive committee of the medical staff which is chaired 

by the medical center Chief of Staff. The executive committee evaluates the materials to determine if medical/clinical knowledge and clinical competence are adequately demonstrated to support re-credentialing and the granting of the requested 

privileges. A final recommendation is then submitted to the medical center director 

who is the authority to grant privileges.

NATIONAL SURGICAL QUALITY IMPROVEMENT PROGRAM (NSQIP)

NSQIP gathers aggregate data from surgical outcomes to determine whether 

there are significant deviations in mortality and morbidity rates for surgical procedures. Since the beginning of Fiscal Year 2007, this information is assembled on a 

quarterly basis. Prior to that time, the information had been gathered yearly. It was 

decided that NSQIP would be a better tool if the data were gathered more frequently. This was reinforced when our NSQIP data was evaluated after the onset 

of this new timing. 

In response to an elevated ratio of observed to expected surgical deaths during 

the first two quarters of Fiscal Year 2007, a NSQIP team conducted an onsite visit 

at the Marion, IL VAMC. This was conducted as part of the NSQIP ongoing program of surveillance of surgical mortality. The site visit was conducted in August 

2007. 

Following a full and comprehensive investigation of the elevated ratio of mortality 

at the Marion VAMC, the Director took immediate action to ensure the safety of 

patients until the completion of the investigation. All in-patient surgery at the Marion VAMC requiring general anesthesia was discontinued immediately. Veterans requiring surgery with general anesthesia were referred to other VAMCs or, if necessary, to non-VA hospitals. VA’s Under Secretary of Health (USH) directed the VA 

Office of Medical Inspector (OMI) to conduct an onsite visit. On September 5–6, 

2007, the OMI conducted a visit at the Marion VAMC and confirmed significant 

issues regarding surgical quality and operation and raised issues regarding the 

management environment at the medical center in general. That report is anticipated to be completed in the near future. The USH requested the VA Office of the 

Inspector General (OIG) to conduct an onsite visit. Those findings are not final at 

this time. To date, five members of the Marion VAMC staff have been reassigned 

to non-clinical areas away from the medical center or placed on administrative 

leave. 

VA promptly notified Congress of the initial finding identified by VA’s ongoing assessment and review processes. VA continues to be responsive to Congressional inquiries, to the extent possible, considering ongoing investigations.

CONCLUSION

Mr. Chairman, VA has multiple tools in place for assessing and evaluating health 

care and they are working, as in this case, to identify irregularities and correct 

them. These tools are part of the ongoing processes that are used in not only revealing the positive but also the vulnerabilities and deficiencies in VA’s health care system. VA acknowledges these findings and seeks to actively address the challenges 

they present. Moreover, the lessons learned are disseminated to health care providers throughout our health care system. 

Mr. Chairman, this concludes my statement. At this time I would be pleased to 

answer any questions that you may have.

Senator AKAKA. Dr. Cross, there are two issues at the heart of 

the situation at Marion. One, did VA do all it could to ensure that 

physicians practicing there were appropriate hires? And, two, when 

deaths and botched surgeries started to arise, did hospital management take appropriate action? Are you confident that VA did everything possible to verify the credentials of physicians? And are you 

11

at this point able to say with certainty that hospital management 

responded appropriately when they were told about problems with 

the surgeon? 

Dr. CROSS. Sir, what I can assure you of is that we have taken 

dramatic, swift, definitive action based on the information we have 

at this time and that we had in August. I am not going to be confident to tell you that I have the complete picture until the investigations are complete. That does include the medical inspector investigation and the IG investigation. But we have found that we 

have enough concerns—we had enough concerns early on in August 

that we took rather definitive action in removing by detailing out 

the medical center director. We detailed out the medical center 

chief of staff and subsequently detailed out the chief of surgery and 

an anesthesiologist. 

As our investigation has continued, we have taken further action, 

which I have listed in my oral statement elsewhere, and some of 

that just occurring within the past few days. 

Senator AKAKA. Your full statement will be included in the 

record, Dr. Cross. 

Dr. Cross and Ms. Enchelmayer, timing clearly poses a problem 

in the process of background checks. Because medical administrators cannot discuss open disciplinary investigations, prospective 

employees may not be aware of serious issues surrounding potential hires. 

The question is: How can the background check process be improved to ensure timely and accurate reporting? 

Ms. ENCHELMAYER. I think that I can honestly say that we have 

a credentialing system in VA that is the envy of most of the health 

care industry. We collect a great deal of information on our health 

care practitioners at this time. The application process using the 

VetPro system is an electronic system that actually requires practitioners to answer the questions that Dr. Cross alluded to in the 

opening statement about actions in their past—voluntary surrenders because they have moved from States, as well as disciplinary 

actions. And they attest to the accuracy of that information as they 

submit their information to us. 

We also ask them for a complete application electronically, which 

includes not only their education and training, but also they are requested to provide us information on all current and previously 

held licenses and registrations that they did hold. They must also 

account for all gaps greater than 30 days from the time that they 

graduated from their professional program, which gives us a full 

background history, and we can compare that work history to the 

information that they have provided to us so that is available to 

the medical staff leadership and the staff at the facilities to review. 

We use the secondary flagging systems of the National Practitioner Data Bank and Health Integrity and Protection Data Bank, 

and we actually also use the Disciplinary Alert Service at the Federation of State Medical Boards, which is not an industry standard. 

We exceed that when we do query the FSMB for information on 

disciplinary actions on physician licensure. And that database has 

been in existence for many, many years. It precedes the National 

Practitioner Data Bank by a significant number of years. So that 

we do get the disciplinary information as well. 

12

When practitioners submit their information, they actually attest 

to the completeness and accuracy of that information, so it is a 

legal attestation and a legal signature that can be used later if the 

information is not complete. 

And then as Dr. Cross said, all information is primary-source 

verified, and we receive all the information that we can possibly receive. 

You asked how we could be helped. The health care industry as 

a whole could be helped because we get the same information every 

other hospital and health care entity gets, and that is public information. So we would have to go beyond what all of health care industry gets at this time. 

Senator AKAKA. Dr. Cross and Ms. Enchelmayer, it is my understanding that doctors’ credentials are updated every 2 years when 

reappointment decisions are made. Is there a process in place to 

ensure that credentials are rechecked as soon as new information 

becomes available in national databases regarding disciplinary actions, malpractice payments, or license suspensions? 

Dr. CROSS. I will ask Ms. Enchelmayer to expand on this, but I 

want to say yes, and we have involved ourselves with that, taken 

advantage of that, because one of the key credentials is the license 

itself. And if action is taken against a license, we do have a system, 

wherever that action was taken, to notify us. 

Kate, can you expand? 

Ms. ENCHELMAYER. I am happy to, sir. 

VA does subscribe through a contract with the Federation of 

State Medical Boards to the Disciplinary Alert Service. So if a 

State Medical Board takes an action against a license, they report 

that action to their parent organization, the FSMB, and they in 

turn alert all of the member boards, which are 70 osteopathic and 

medical boards, as well as anybody who subscribes to that Alert 

Service, within 24 hours. I personally receive those alerts, and we 

turn them around to the medical centers for immediate processing, 

and they are to bring the information to the attention of medical 

staff leadership for review and action, as well as primary-source 

verify the information with the State Medical Board that led to 

that action. 

Senator AKAKA. Thank you very much. 

Senator BURR?

Senator BURR. Thank you, Mr. Chairman. 

Dr. Cross, I will direct my questions to you, but if you would like 

others to answer them, please feel free. I notice that you did not 

mention in your testimony as to whether or not you believe the VA 

credentialing or privileging problems might have led to any of the 

fatalities at the Marion VA facility. Do you believe that the VA 

credentialing or privileging process is at fault? 

Dr. CROSS. I think it is too early for me to assign fault, and I 

think that is where the responsibility will be assigned in the IG 

and the MI investigation. But I do have some concerns. I have concerns that we follow through, and that once privileges are granted, 

that we make sure that those privileges remain what is appropriate for that individual and that facility. 

Senator BURR. When you say ‘‘appropriate for that individual,’’ 

the scope of their——

13

Dr. CROSS. The scope. 

Senator BURR [continuing]. Surgical or physician practice? 

Dr. CROSS. Correct. 

Senator BURR. Thank you. Was the VA policy adequately followed at the Marion VA facility? 

Dr. CROSS. Based on the knowledge that I have at this time, understanding the investigation is continuing, it appears that they 

checked all of the things that I have listed off here, which were the 

appropriate things to do. 

Senator BURR. Do you care to share with the Committee your 

thoughts as to what happened or who might be responsible? 

Dr. CROSS. Sir, I am respectfully not going to try and assign responsibility, but I think the focus of our concerns relate to the 

privileging aspect and the monitoring of the privileging and to 

make sure that the staff onsite are well aware of exactly how performance is carried out. 

Senator BURR. The Chairman asked a question relative to one’s 

privileging and how that might be affected if something new was 

gleaned in that 2-year period. Let me ask a slightly different question. 

The process you go through for credentialing and privileging is 

a very in-depth process that you explained. I would like to hear 

more about how a medical professional already employed by the VA 

would go about maintaining their privileges. 

Dr. CROSS. I will ask Kate Enchelmayer to respond. 

Ms. ENCHELMAYER. I am happy to answer that question, sir. Actually, the privileges are granted for a period not to exceed 2 years, 

but throughout that 2-year period, we have many ongoing monitoring activities at the local facility level, and that information 

should be being routinely analyzed by the service chiefs who are 

supervising the practitioners on that service and by the executive 

committee of the medical staff and the various committees of the 

hospital, looking for any questions that might arise on a practitioner’s clinical practice during that period. 

At a minimum, though, every 2 years all the practitioner performance data is to be reviewed and is to be analyzed as that practitioner renews his or her privileges. 

Senator BURR. Dr. Cross, let me go to that timeline, if I can. I 

am not sure that any of us know exactly what every line means, 

but let me just ask you a question. Given where you start on that 

timeline, which is recognizing in some of the outliers there might 

be a problem here—I take for granted here that is what the first 

arrow is—and ending with the November 1, a general surgeon, an 

orthopedic surgeon, and another surgeon had privileges limited, 

meaning there has been a review not just of a doctor-implicated but 

the entire medical staff. Do you think that the amount of time that 

it was taking to reach each one of those steps is consistent with 

what we would find in any other medical center in the country? 

Dr. CROSS. Sir, I would be very impressed if anyone could have 

ever done it faster. This is a quick response, getting three teams 

assembled, three teams conducting the investigations, and we took 

actions, not waiting for all the teams to come back and report. We 

took actions based on the information that we got early on. That 

action that we took was pretty dramatic in terms of removing from 

14

the facility key leadership individuals. And we did that early on in 

that cycle, before the IG report came back, before the MI report 

had been finished. We thought that we had enough concern—and 

we did—to take action to make sure that our patients were protected, and we did that early on in the cycle. 

I want to emphasize one thing that you asked about. Our investigation is not limited to just one individual. We are taking the 

broader picture, checking the entire situation, institution, others, 

taking the broadest possible look to make sure that our patients 

can be reassured. 

Senator BURR. Do you have any concern as the Principal Deputy 

Under Secretary of Health, your title, that the Inspector General 

is looking at this investigation with all the powers his office brings? 

Dr. CROSS. I know the Inspector General and his staff quite well 

on the medical side, and they are focused on detail, and they have 

remarkable determination to get to every one of those details. So, 

yes, I have absolute confidence in them. 

Senator BURR. Thank you, Dr. Cross. 

Dr. CROSS. I also have great confidence in their independence. 

Senator AKAKA. Thank you, Senator Burr. 

Senator DURBIN?

Senator DURBIN. Dr. Cross, I listened to your description of the 

process that is followed to credential doctors into the VA medical 

system. How much of that decisionmaking and investigation is 

done at the local level by the Marion hospital, for example? 

Dr. CROSS. There are elements of credentialing and privileging 

that are both done at the local level, but privileging is the second 

phase of that, which is almost purely a local process. I will ask 

Kate to correct me if I am wrong. 

Ms. ENCHELMAYER. That is a correct statement. Privileging actually has to be facility-based because the privileging process starts 

with what is available at the medical center, and what resources 

are available. And then you start to look at determining what will 

be performed at that facility, which is then followed by matching 

that with the practitioners who will be delivering the care. 

Senator DURBIN. The lengthy and elaborate process that you described for credentialing and recredentialing physicians, I am trying to understand if that is being done at each of the 150 or so different VA medical centers or is being done in some central location? 

Ms. ENCHELMAYER. It is being done at each independent—each 

individual facility because of the fact that the privileging process 

must be done at the local facility level. And the credentials are 

what feed to granting to those privileges to the individual practitioners. 

We implemented in 2001 a standardized electronic credentialing 

system, which does standardize the credentialing process across the 

agency so that the credentialing done in one facility is the exact 

mirror of what is done in every other facility. 

Senator DURBIN. So assuming there is a vacancy for a surgeon 

in a veterans medical center, do I understand then that the local 

people at that medical center get into this process of finding out 

who is available and then determining their qualifications to serve 

at that medical center? 

15

Ms. ENCHELMAYER. Yes, sir. 

Senator DURBIN. Do I understand that you are promulgating a 

new policy as of October 2nd this year relative to credentialing? 

Ms. ENCHELMAYER. The credentialing and privileging policy is a 

very dynamic policy, and it has been republished numerous times, 

and, yes, the most recent publication was October 2nd. 

Senator DURBIN. What is the most significant change in this new 

approach of October 2nd? 

Ms. ENCHELMAYER. The October 2nd policy actually incorporated 

a number of other directives that we had put in place concerning 

the query to the Federation of State Medical Boards, which was 

mandated back in 2002; expedited credentialing to facilitate the 

credentialing process at the facility level slightly in accordance 

with the Joint Commission standards. It also incorporated some 

policy on telemedicine and teleconsultation, which had been a separate policy. It was a unification policy as well as also clarifying a 

number of issues over questions that have been raised for a number of years. 

Senator DURBIN. There is obviously some element of self-reporting going on here by the applicants. For example, you have one 

physician, a surgeon, who was put on administrative leave due to 

failure to disclose that he was licensed in a particular State. So I 

take it that, at least at some stage in the process, you depend on 

the applicant to tell you which States he is licensed in. 

Ms. ENCHELMAYER. That is a true statement, sir. We also do 

have, though, in policy a requirement to analyze the work history 

and to determine where somebody practiced and if there was potential for them to have a license in a State. 

Senator DURBIN. How long did that particular surgeon practice 

before you discovered that he was licensed in a State he had not 

disclosed? 

Ms. ENCHELMAYER. I did not do the immediate credentialing, sir. 

I cannot answer that. 

Senator DURBIN. Dr. Cross, do you know? 

Dr. CROSS. I will have to get that for the record, sir. 

Senator DURBIN. All right. Let me ask you this: As I read the 

timeline here, I was surprised at a new entry I was not aware of: 

November 1st, a general surgeon, an orthopedic surgeon, and a 

genitourinary surgeon had privileges limited at Marion. So I would 

like to ask you at this point, with the resignation of Dr. Mendez, 

with the administrative leave given to another surgeon for failure 

to disclose his licensure in another State, and now with privileges 

limited, can you give me some kind of a feeling about how many 

of the surgeons in the surgical team at Marion have either resigned, been suspended, or have had their privileges limited? 

Dr. CROSS. Sir, to date, five members of the medical center—five 

members of the Marion VAMC staff have been reassigned to nonclinical areas away from the medical center or admin leave. Also, 

a surgeon resigned, the original, upon notice of the pending investigation, and the VA notified the Illinois Medical Board, as we 

should have done. We did that. And subsequent to the initiation of 

the investigation, the privileges of three other surgeons at the Marion facility have been limited, and that is recent. 

16

Senator DURBIN. What does this tell us about what seems to be 

a comprehensive credentialing and licensing process and the quality assurance process that, at a facility like Marion, questions 

would be raised about the disclosures made or practices followed by 

so many surgeons? 

Dr. CROSS. I will start the answer, and I will ask Dr. Almenoff 

to support me on this. But right now, in our reviews, the multiple 

reviews that are being done, they did not dot the ‘‘i’’ and cross the 

‘‘t’’ and, you know, we are taking action. 

I will ask Dr. Almenoff to be more specific. 

Dr. ALMENOFF. In total, there were three physicians that were on 

administration leave, and then there are three physicians that are 

also on limited privileges at this point. 

The privileging process at the facility is the heart of what we are 

looking at, at this point. Privileging is really determined at the 

local site, and it is based on the capabilities of the facility, it is 

based on the capabilities of the provider, and it is based on the 

training that they have had in that specific area. 

Senator DURBIN. How many doctors are there in the VA medical 

system? 

Ms. ENCHELMAYER. Thirty-six thousand. 

Senator DURBIN. Is it my understanding that there is some review underway for the credentialing of all of these doctors? 

Ms. ENCHELMAYER. Yes, sir. What we did, as soon as this came 

to light, was since we do have an electronic system, we actually 

looked through the system at 56,000 licensed independent practitioners, so that goes beyond just the physicians but to anybody 

practicing independently. And we have retrieved 17,000 names that 

are under review right now. These are people who answered the 

supplemental questions yes, and I will tell you my name is in that 

list because I allowed a license to lapse in good standing when I 

moved from a State, so I answered yes to that question, just like 

a number of other people did, and anybody who has a positive answer to a previous disciplinary action by a licensing board and anybody who has a report from the National Practitioner Data Bank. 

We actually brought in seven field staff to help us initiate the 

analysis, and right now the data is being reviewed at each individual facility. We expect to have an initial preliminary review of 

that data by early December with a final report to the Under Secretary by the end of December. 

Senator DURBIN. Was this all brought on by the situation in Marion? 

Ms. ENCHELMAYER. Yes, sir. 

Senator DURBIN. So is it fair to say that the Marion situation, 

as tragic as it was, is that the canary in the cage that gave some 

indication to the VA that something needed to be looked into here 

more closely to protect the veterans who were coming in for medical care across America? 

Dr. CROSS. Sir, I do not know that the situation in Marion, the 

concerns that we have about the individuals involved, necessarily 

relate to other medical centers, but we are cautious people, and out 

of that caution and care and concern for the patients, we chose to 

go do this very broad review. 

17

Senator DURBIN. I see my time is up, but I just want to close 

with a comment. It is an interesting system where 150 different 

hospitals are going through this credentialing process, privilege 

process. I can understand that, as it was explained. But it also 

means it has been diffused into a lot of different places and a lot 

of different people. And now that you are doing the review, it is a 

central review where questionnaires are being sent, which leads me 

to ask whether or not the initial credentialing process should have 

had more central force in it, more central involvement so that there 

are certain standards that we can be sure of, whether we are dealing with a rural VA hospital, an urban VA hospital, or some particular challenge. 

Thank you. 

Senator AKAKA. Senator Murray? 

Senator MURRAY. Thank you, Mr. Chairman. I was going to ask 

you what assurances we can give our servicemembers that this is 

not more of a systemic failure. I assume your answer would be that 

you are doing this broad review now as a result of what happened 

at Marion, correct? You have 17,000 physicians that you are now 

going back through and looking at. 

Dr. CROSS. Seventeen thousand independently licensed providers, 

I believe, Senator. But there is also one more thing to say. We discovered this. It was our internal processes that picked this up. It 

was not some external source that brought this to our attention. 

And I think that should provide at least some reassurance as well. 

Senator MURRAY. I am not sure I understand that. I thought 

that——

Dr. CROSS. The internal systems that we have in place. 

Senator MURRAY. But I thought that this came about as a result 

of deaths that occurred at Marion VA. 

Dr. CROSS. Our ability nationwide to pick up those and monitor 

those in terms of national standards is what caused us to trigger 

the investigation. 

Senator MURRAY. Well, can you tell me what some of the reasons 

are that the screening process that was used by the VA could have 

missed the problems that were documented at the other facilities 

that physician worked at? 

Dr. CROSS. I will ask Kate to assist me on this, but my understanding—is that the steps that we described here were done. Also, 

we obtained from his State and from his associates and from his 

supervisor letters of recommendation. I believe those letters will be 

part of the ultimate record that is released. 

I should tell you that I can characterize them as being very positive, often seeing, you know, the best surgeons, highly technically 

competent; we would hire them back in a minute. And so it was 

with those kinds of references, a full, unrestricted license, 30 years 

of practice, that were factors that came into being at that time. 

Senator MURRAY. So how can we assure that this does not happen again? 

Dr. CROSS. Again, responsibility will be assigned, but my focus 

lies with the staff onsite who monitor day to day and who know 

their surgeons, know the cases that they are doing and make judgments about the scope of surgery that should be done by that surgeon at that location. 

18

Senator MURRAY. Dr. Cross, can you share with this Committee 

the rate of fatal and non-fatal patient safety events that have occurred at the Marion VA since the beginning of 2006 compared 

with some of our other VA hospitals across the Nation? 

Dr. CROSS. I do not think I have that with me, Senator. I can 

get that for the record. 

Senator MURRAY. Does anybody at the table have that? No idea 

at all? If you could share that with the Committee, then, I would 

appreciate it as soon as possible. 

Can I ask you, after the first couple of incidents occurred at the 

Marion VA, why was this physician allowed to continue performing 

surgery? 

Dr. CROSS. I think that is a good question that the IG and the 

medical inspector’s reports will shed more light on. One possible 

explanation is that at the time and at the place where they reviewed those cases, they thought there were good explanations that 

explained what had happened. 

Senator MURRAY. OK. Is there anything systematically to review 

a physician after incidences occur? Or is it just kind of haphazard? 

Dr. CROSS. Well, unlike our colleagues in the civilian world, we 

do have an additional safeguard, and that is the NSQIP system. 

And so even if the local safeguards do not work out well, we have 

a national system unlike any others that helps us as an additional 

safety net. 

Senator MURRAY. How many deaths does it take to activate that? 

Dr. CROSS. It is a statistical—it is not an absolute number. It is 

a statistical technique that is based on comparison to a national 

standard. 

Senator MURRAY. Were the procedures that were being performed particularly complex, or were they routine? 

Dr. CROSS. I think some were routine and some were more complex than I would have expected. 

Senator MURRAY. I am certain that we will want to review the 

IG’s report when it comes out. Let me ask you a more broad question because it is one that I think we all need to be aware of, and 

that is that we are really trying to hire more physicians to deal 

with the high number of incoming veterans, both from the current 

war as well as previous wars, and Congress has allocated funds 

over the last year to do that. 

I am particularly interested in our rural VA facilities where we 

know in the general health care system they already have a hard 

time accessing physicians. 

Should we be concerned that with trying to reach out and hire 

as many physicians as possible, particularly in our rural facilities, 

that we may run into more problems like this? 

Dr. CROSS. Whether the facility is rural or urban, the same 

standards have to apply. I think what changes at a rural facility 

is the scope of surgery that we might do. 

Senator MURRAY. Have the smaller rural VA facilities like the 

one in Marion seen an increasing number of veterans from this current conflict? 

Dr. CROSS. They certainly see more, and we have with us today 

Dr. George Maish, from a similar facility in Lebanon, Pennsylvania. Dr. Maish? 

19

Senator MURRAY. Perhaps you could answer what you are seeing 

at your facility. 

Dr. MAISH. Senator, our facility has grown from 1999 to the 

present from taking care of 19,000 individuals to taking care of almost 41,000 individuals. So we have had to recruit personnel—doctor, nurse, PA, nurse practitioner—to care for these people. We are 

very busy in the recruiting business because of the rapid growth 

in the demand for services. 

Senator MURRAY. And you come from a fairly rural facility; is 

that correct? 

Dr. MAISH. I think I would be considered rural. I am in a town 

of about 20,000 in the farming country of Pennsylvania. I am 35 

miles from Harrisburg, 90 miles to Philadelphia. 

Senator MURRAY. And you have gone from 19,000 in what year? 

Dr. MAISH. 1999. 

Senator MURRAY. More than double today. 

Dr. MAISH. Yes, in an 8-year period, yes. 

Senator MURRAY. I assume, Mr. Chairman, that this is fairly 

similar to what a lot of our rural facilities are facing today. And 

what has been your experience in trying to hire physicians and 

medical personnel? 

Dr. MAISH. It is a difficult job. I run a general surgical residency 

program, and I am integrated into the College of Medicine at Hershey Medical Center. Thus, the personnel that I seek to hire, I 

have to be able to present to the College of Medicine to hold an assistant professorship. So, I have to look at standards. I have needs. 

People have issues. If you look at my chronology, I graduated high 

school in 1960; I graduated from college in 1964; I graduated from 

medical school in 1968; I finished my surgical residency in 1973. 

When I have breaks in that process, I have to ask the practitioner, ‘‘Where were you that year? What did you do?’’ There are 

often good explanations, and there have been some that were in 

jail. I dropped that process immediately. 

People do not disclose adverse rulings from licensure boards. 

They are instructed by their personal attorney not to, unless they 

are directly asked. I engage this process. I believe the process is 

excellent to screen, but I have to execute my responsibilities in the 

recruiting of new physicians. 

Dr. CROSS. I think, Senator—and Hershey is a growing area, so 

a lot of people have, in fact, turned up in that environment. And 

to complete my answer on one of your other questions, the NSQIP 

does cover all of our hospitals where we do surgery, including 

rural. 

Senator MURRAY. OK. Well, I think, Mr. Chairman, my point is 

that we are seeing an increased intensity and need in our VA facilities across the country. In our rural and in our urban, but in our 

rural hospital facilities in particular, they are trying to recruit very 

fast. That means we have to be even more diligent in checking credentials because, as we all know, that is when people start slipping 

through the cracks. And I look forward to the hearing that I hope 

we will have once the IG report is complete, and I hope that the 

VA can come to us and really talk to us about what they are doing, 

particularly in these communities, to make sure that we get the 

20

best, the brightest, and those who are credentialed and safe to perform surgery. 

Thank you very much. 

Senator AKAKA. Thank you, Senator Murray. 

I want to thank the first panel. Dr. Cross, what you said is something that is of paramount importance for us—the well-being of our 

patients. That is why we are here—the VA patients. I primarily 

wanted to focus today on the hiring practices and quality control 

as well as the credentials of those who serve in those areas. And 

we want to fix any problems. And so I hope what is happening 

today will result in that. 

May I call on Senator Durbin? 

Senator DURBIN. Dr. Maish, I am not sure if this question is for 

you or for Ms. Enchelmayer or Dr. Cross, or perhaps all of you. In 

this particular case, this doctor surrendered his license in the State 

of Massachusetts and was characterized by the State as having 

done so for a non-disciplinary reason. And the explanation, I understand, I gave earlier, that he was no longer going to practice there 

and so forth. 

I would like to ask you: Is that the kind of thing that would raise 

a question in your mind even if it were characterized as non-disciplinary? 

Dr. CROSS. Sir, it raised the question in our minds as well and 

in the staff there. I do have to be precise. He did not relinquish 

his license. It is a technicality, but he agreed to not practice in the 

State. He still had a license. And the response by our staff, as I 

understand from the preliminary medical inspector’s report, is that 

they thought that was of concern as well and actually called to the 

State of Massachusetts to get more information. 

Senator DURBIN. And did they get more information? 

Dr. CROSS. The only information they got was the words ‘‘it was 

a non-disciplinary action.’’

Senator DURBIN. Well, the first time you explained that to me all 

the red flags started to wave. I know as a lawyer, it looks like 

there was an agreement reached here: We are not going to take 

your license away, but we do not want you practicing in this State. 

We will put it down as non-disciplinary and that will be the end 

of it, but don’t come around here anymore. And the lawyer may 

have said, ‘‘Let’s get out of here. You can still practice at the VA 

facility in Marion. You still have an Illinois license. Let’s move on.’’

Now, maybe that is a cynical view, but with the limited information which you have, it could also be an accurate view. And I would 

say, Dr. Maish, as you went through step-by-step and day-by-day, 

this was a suspicious thing that occurred, and had action been 

taken at that point, it would have been taken before many of these 

fatal surgeries. 

Senator AKAKA. Well, again, I want to thank our first panel for 

your testimony and for your responses. 

Senator AKAKA. I will now introduce the second panel. I want to 

extend my warm welcome and my warm aloha to the second panel. 

I appreciate each of you being here today and look forward to your 

testimony. 

First, I welcome Randall Williamson, who is Director of Health 

Care for the GAO. 

21

I also welcome Tammy Duckworth, Director of the Illinois Department of Veterans’ Affairs. Ms. Duckworth has testified before 

this Committee twice before, most recently during our hearing last 

March, which examined health care services for returning 

servicemembers. I am happy to see you again, Tammy. 

I also welcome Steven McCarty, a veteran from Bedford, Texas. 

Mr. McCarty served in Iraq in 2006 and 2007, and thank you for 

making the trip to testify today. 

Each of your statements will appear in the record of today’s hearing, and I ask that you each limit your direct testimony to no more 

than 5 minutes so that we have time for questions. 

Mr. Williamson, will you please begin with your testimony? 

STATEMENT OF RANDALL B. WILLIAMSON, ACTING DIRECTOR, 

HEALTH CARE, U.S. GOVERNMENT ACCOUNTABILITY OFFICE 

Mr. WILLIAMSON. Thank you, Mr. Chairman and Members of the 

Committee. I am pleased to be here today to discuss our May 2006 

report on VA’s processes for credentialing and privilegingVA physicians. Since Dr. Cross has already given you a fairly detailed overview of VA’s credentialing and privileging process, I am going to 

limit my remarks today to the findings of our 2006 report on compliance with these processes at VA facilities we visited. I will also 

discuss the action VA has taken on the recommendations we made 

to improve the privileging process. For this work, we visited seven 

VA facilities, reviewed physician files, and interviewed VA officials 

as these facilities and at VA headquarters. 

At the facilities we visited in 2006, we found that all seven facilities were complying with the key credentialing requirements that 

we examined, including requirements to verify physicians’ State 

medical licenses, to verify information provided by physicians on 

their involvement in malpractice claims, and to query available 

databases to determine physicians’ involvement in disciplinary actions and malpractice claims. We also looked at compliance with 

privileging requirements, including whether facilities were 

verifying physicians’ training and experience, assessing physicians’ 

clinical competence and health status, and considering a physician’s performance while at VA when renewing his or her clinical 

privileges. While the seven facilities were complying with most of 

the privileging requirements we examined, we noted compliance 

problems with certain aspects of privileging. 

First, we found that six facilities were not using or obtaining appropriate data to evaluate physicians’ performance while at VA. 

The seventh facility was not using any physician performance data 

in making its privileging decisions for reappointment of physicians. 

Second, three of the seven facilities were not forwarding information within the required 60 days on paid VA medical malpractice 

claims to a VA office that makes determinations on whether substandard care has occurred. Delays in providing this information 

could prevent determinations of substandard care by physicians 

from being considered as part of the facility’s privileging process. 

Finally, we found that one facility we visited lacked internal controls that would have helped identify that the privileging process 

had not been completed for 106 of its physicians within the 2 years 

required. As a result, these physicians were practicing at the facilVerDate 0ct 09 2002 14:37 May 20, 2008 Jkt 000000 PO 00000 Frm 00025 Fmt 6633 Sfmt 6601 H:\PS41451\DOCS\41911.TXT SENVETS PsN: PAULIN
22

ity with expired clinical privileges. None of the other six facilities 

we visited had internal controls in place that would have prevented 

a similar situation from occurring. 

We made recommendations to improve VA’s physician privileging 

process and to remedy each of the three problem areas that we 

found. VA concurred with our findings and recommendations and 

reported that it has implemented measures to improve its privileging process. However, we have not visited or examined records 

at VA facilities since 2006 to determine whether these improvements are in place and whether VA facilities are complying with 

the current credentialing and privileging processes. 

VA’s privileging improvements include:

(1) a policy issued last month elaborating on the appropriate 

types and sources of physician performance information that could 

be used by its medical facilities during the privileging process. 

(2) stricter procedures to enforce prompt reporting of information 

about paid malpractice claims, including notification to medical facility directors and VA headquarters about delinquencies. 

(3) establishment of internal controls to ensure that privileging 

information is kept accurate and current at its facilities.

Mr. Chairman, this concludes my statement. I would be happy 

to answer any questions that you or other Members may have. 

[The prepared statement of Mr. Williamson follows:]

PREPARED STATEMENT OF RANDALL B. WILLIAMSON,

ACTING DIRECTOR, VA HEALTH CARE

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Senator DURBIN [Presiding]. Secretary Duckworth, you are next 

to testify. Glad to see you here. 

STATEMENT OF TAMMY DUCKWORTH, DIRECTOR, ILLINOIS 

DEPARTMENT OF VETERANS’ AFFAIRS 

Ms. DUCKWORTH. Well, I would like to thank my Senators, Senator Durbin and Senator Obama, for their aggressive actions leading to the examination that we are now seeing at the Marion VA 

Medical Center. Senator Durbin and Senator Obama have long 

been advocates of veterans here in Illinois. 

I would like to have my additional comments added to the record 

from the written statement. 

Senator DURBIN. Without objection. 

Ms. DUCKWORTH. My biggest concern, sir, is that there is a lack 

of consistency across the Nation when it comes to the local level for 

implementing many of the VA’s national programs, and I am seeing this in our rural communities especially, specifically Danville 

VA and Marion VA. Both are in rural central and southern Illinois. 

The problem that we have is that whether it is a policy of allowing veterans to access outside physicians or whether it is this 

credentialing issue, there is a national policy, but it is selectively 

enforced at the individual medical center level. I will give you an 

example with Danville VA. 

Many of the patients at Danville VA actually have to travel upwards of 3 to 4 days just to get a simple chest x-ray, while there 

are doctors and physicians near their home towns where they can 

actually get these procedures completed without having to spend 

multiple overnights. The Danville VA is very reluctant to allow the 

patients in its community to access their outside health care, even 

though a procedure already exists for them to do so in the Federal 

VA system. So while there is great national policy and procedures 

written someplace in a manual, oftentimes it is the local administrators, the local hospital administrators, who interpret those policies who do not actually administer them. 

The timeline that we saw earlier today gives me great concern 

because we are so focused on what happened after the ten deaths 

occurred, we are not looking at what happened up to that point. 

Did the local facilities actually implement those processes, those 

wonderful processes that actually lead the Nation in terms of 

credentialing? I am also additionally concerned with the fact that 

a doctor in the Marion VA does not have to hold a license in Illinois 

to practice in Illinois. That is a great concern to me. I know that 

in our four nursing homes that we operate by the State of Illinois 

for veterans, our doctors that operate there hold licenses in Illinois 

and also have privileges at the local hospitals outside of our own 

system. So that there is some sort of a cross-check, not only of we 

verifying them but they also hold privileges at the local community 

hospitals as well, who also go through their own process of 

verifying the credentials of the physician. 

Throughout this, I think it is important to say that I do not ask 

for any shutdowns of any rural VAs. In fact, we need more VA hospitals and clinics, especially in our rural communities. In Illinois 

alone, over 50 percent of our recruits come from areas outside Chicago’s Cook and collar counties, and we are seeing an increased 

39

rise in veterans’ needs, not just from the young veterans coming 

home from Iraq and Afghanistan. The Federal VA estimates that 

there are approximately 8,122,000 Vietnam veterans who are now 

entering their mid-60’s, at a point when their medical needs increase. Many of the illnesses, such as those caused by Agent Orange, are just now appearing in their system—leukemia, cancers, 

those types of things. There is going to be a greater demand for 

more complex procedures for older veterans, and this is happening 

across the Nation. 

As a percentage of that 8 million veteran number, I am estimating that Illinois alone has approximately 389,000 Vietnam veterans. Many of these veterans have not accessed VA care up until 

this point. Many of these veterans live a long way away from the 

nearest VA clinic or hospital. 

So I would like to just summarize my testimony by saying that 

some of the suggested solutions are that the USDVA needs to either open more VA clinics and Vet Centers, or they need to start 

certifying private practitioners to provide medical services and give 

the veteran this option to access care outside of the VA clinic or 

the VA hospital themselves. We need to ensure, however, that 

there is no drop in standard of care for our veterans. We also need 

to identify major civilian medical facilities, such as university 

teaching hospitals or other large networks, where the physicians 

who have privileges at the VA hospital should be required to also 

have privileges, surgical privileges, practice privileges as these outside facilities to provide a cross-check, as it were. Not only is there 

a VA system that is being implemented by the local VA hospital 

administrator, but if that physician is required to have a licensing 

requirements in the State where he is practicing, as well as privileges at an outside hospital, I hope that will help to reinforce and 

provide a back-up. 

There simply is just not enough time for the USDVA to try to 

recruit enough physicians to meet the current need, and I think 

that it is time to think a little outside the box. And I thank you 

for calling this hearing, even at this early stage, because I think 

it will allow us to move forward in terms of future questions that 

need to be raised. 

I want to say, Senator Akaka, that it is great to see you in that 

chair, sir. Thank you. 

[The prepared statement of Ms. Duckworth follows:]

PREPARED STATEMENT OF TAMMY DUCKWORTH, DIRECTOR,

ILLINOIS DEPARTMENT OF VETERANS’ AFFAIRS

Mr. Chairman, Members of the Committee. It is a pleasure to be asked to testify 

before you today on behalf of Illinois Governor Rod Blagojevich and the Illinois Department of Veterans’ Affairs. This Committee is to be commended for drawing attention to the very important issue of quality of care for our returning Veterans and 

servicemembers. 

I want to thank my Senator, Senator Durbin, for his aggressive action which led 

to the examination we are now seeing at the Marion VA Medical Center. Sen. Durbin has long been an advocate for Veterans and their care. 

The Illinois Department of Veterans’ Affairs assists Illinois’ Veterans in obtaining 

their State of Illinois Veterans’ benefits as well as their Federal Veterans’ benefits. 

We have 74 Veterans Service Officers on staff who are certified by the U.S. Dept. 

of Veterans’ Affairs (USDVA) to process, represent and make appeals on behalf of 

the Veteran in their claims for compensation from the USDVA. State of Illinois benefits for Veterans are in addition to Federal benefits and range from generous eduVerDate 0ct 09 2002 14:37 May 20, 2008 Jkt 000000 PO 00000 Frm 00043 Fmt 6633 Sfmt 6621 H:\PS41451\DOCS\41911.TXT SENVETS PsN: PAULIN
40

cational, mortgage loan, and other financial assistance to our four Veterans’ Homes 

where Illinois’ Veterans may live out their remaining days with the dignity and care 

they deserve. As the Director of this agency, I want to be clear that we do not have 

any jurisdiction over the USDVA’s operations, to include the various USDVA Veterans’ clinics, hospitals and Vet Centers. 

While we may not have the responsibility of licensing and overseeing the actual 

hiring of doctors for the Federal facilities in Illinois, we do work closely with all our 

Veterans and try to find the most reasonable and highest quality health care accommodations available. 

As the Director of IDVA, I see every day the struggles of families as they prepare 

to drive long distances to a health care facility. These struggles impact spouses, parents, and children. And when in a rural area, these drives and travels take a further toll on our servicemembers and Veterans. We cannot afford to have doctors who 

are not suited for license practicing medicine in any of our facilities. And we cannot 

have disparities in the quality of care that is provided at our rural and urban facilities. 

Statistics vary on the actual number of U.S. military recruits from rural communities, but they all indicate that a disproportionate percentage of our all-volunteer 

military are from rural areas, and thus a disproportionate share of deaths and injuries are occurring within our rural recruit population. In Illinois, over 50 percent 

of our military recruits entered the service from a county outside the city of Chicago’s Cook and collar counties. As such, maintaining facilities such as Marion, yet 

improving the quality of care provided, is essential to DOD’s and the VA’s ability 

to care for our Soldiers once they return home from their service to our Nation. 

In Illinois we have a significant rural population who live a long distance away 

from the nearest metropolitan area where the USDVA typically locates its Veterans 

servicecenters, clinics and hospitals. This poses a significant access issue for our 

Veterans. Accordingly, the IDVA has responded by opening 51 offices throughout the 

state to provide Veterans with a location to obtain assistance in applying for their 

USDVA benefits. Once approved, however, Veterans still often have to travel a long 

distance in order to obtain care, often involving multiple overnights away from home 

as they wait for the various once-a-day shuttle bus services. It is normal for a Veteran in central Illinois to have to travel fours days away from home roundtrip, for 

a single doctor’s visit, sometimes for a procedure as simple as an x-ray. 

More personally, as an injured Veteran I’ve seen first hand what it is like to receive care in our VA system. In particular, I want to highlight the stresses of traveling to get care as well as the impacts that these stresses have on the families of 

Veterans. I can attest to the hardship on my family and employer. I live in suburban Chicago. To access my VA hospital basically takes an entire day off from work 

because of the long drive times as well as the common experience of long waiting 

times to see medical professionals, obtain pharmacy services, etc. Now, I’m the Director of a state Veteran’s agency. I would not be surprised if I routinely receive 

more conscientious service than most. If I find some of these things challenging or 

difficult, imagine how a 20-year-old Soldier who has never interacted with the system feels. Not to mention, how does a 70-year-old Veteran who can no longer drive 

obtain the services that he earned and now needs? 

The VA system faces new challenges as a result of the wars in Iraq and Afghanistan. The patient profile in the VA is changing. More wounded Soldiers are surviving very serious injuries. We face new types of injuries, such as Traumatic Brain 

Injury and an increase in poly trauma cases as well as servicemembers facing Post 

Traumatic Stress Disorder. With the all-volunteer military, we are now seeing a 

much larger patient load that is geographically disbursed around our country. 

With these new demands, the VA hospitals will be under increased pressure to 

find more doctors to deliver quality care. I repeat, QUALITY care. The VA must ensure that its hiring procedures do not allow anyone to cut corners and compromise 

excellence as hiring is ramped up. That pressure is likely to be most acute in hospitals located in rural and underserved areas. The VA must put procedures in place 

to ensure that only qualified doctors are hired and that these medical professionals 

are given the cultural training that comes with the unique culture of the military. 

At the end of his life my father could be a difficult patient. However, if a doctor 

called him by his military rank and told him there were lower ranking Vets who 

were ill and needed to have priority over him, my dad would have gladly slept in 

the hallway to make sure that the lower ranking Soldier was cared for. 

Our VA medical system must meet the challenge our young Veterans’ have as 

they return with new needs and at the same time it must expand its services to 

meet the demand of the boom in Vietnam Veterans re-entering the VA system. 

Many of these Vietnam Vets have not used VA services previously, but are now entering their mid-60’s with all the associated diseases and illnesses that comes with 

41

their age. We are also dealing with injuries that have taken over 30 years to develop, such as cancers, diabetes and other conditions that result from exposure to 

Agent Orange. According to the State of Aging and Health in America 2007 Report, 

the cost of providing health care for an older American is three to five times greater 

than the cost for someone younger than 65. 

So the USDVA is now faced with our young servicemembers returning home and 

entering the VA medical system at the exact same time that the medical needs of 

our Vietnam Veterans will be increasing. The amount of money this is going to cost 

the Nation and each individual state is tremendous. In addition, we don’t have 

enough room at our facilities—state or Federal—to take care of both eras at once. 

The dedicated staff at the USDVA medical hospitals is already overworked and 

understaffed. Let me give you an example: The USDVA estimates that there are 

8,122,000 Vietnam era Veterans in this country. I estimate, based on percentage of 

Veterans in Illinois that we are home to 389,856 Vietnam Veterans. The Illinois Department of Veterans’ Affairs operates four state Veteran homes, which are longterm care facilities. Our 1,000 beds are almost at full capacity and already house 

100 Vietnam Veterans. The number of Vietnam Veterans seeking to enter our Veterans’ homes will only increase as will the number on the waiting list. In response, 

we are in the planning stages to build another new Veterans’ home. The fact is that 

right now most VA systems, at the state or the Federal level, are not ready to handle both eras’ Veterans entering the VA system at the same time. Illinois is working 

to be ready with the first of the expansions to our Veterans Homes opening next 

summer and by investing over $50 million in new programs aimed at young Veterans in just 2007 alone. 

What the USDVA needs is to either open more VA clinics and Vet Centers or to 

certify private practitioners to provide medical services and give the Veteran this 

option. While there is already a system in place within the USDVA for Veterans 

to use private medical care facilities, this system is uneven across the Nation. In 

central Illinois, the Danville VA facility is so unyielding that it actually forces its 

Veterans to endure overnight travel to get a simple x-ray performed instead of using 

a local clinic minutes away from their home. By identifying major civilian medical 

facilities, such as University teaching hospitals or other large networks, the USDVA 

could ensure that our Veterans receive the needed quality care that they deserve. 

I must caution, however, that any privatization of VA care be conducted with extreme supervision to insure that there is no lowering of standards and quality of 

care for our Veterans. 

An additional way that the USDVA is not ready to handle our Veterans’ needs 

is in technology. The USDVA has superior expertise in many areas and can meet 

Veterans’ needs if the Veteran can afford to travel to the appropriate VA facility. 

However, in other areas, the VA is far behind current developments and will be unlikely to catch up and adequately meet Veterans needs at the same time. For example, in the case of prosthetics, the VA is not ready and our Veterans cannot afford 

to wait for them to play catch-up. My VA hospital, Hines, is superior in blind and 

spinal cord rehabilitation, but the prosthetics department, while eager to meet my 

needs, is many decades behind in prosthetics technology. I now receive care at Hines 

for my primary medical care, but also continue to return to Walter Reed for prosthetics—paying for my own travel costs. I also travel to a specialist in Florida for 

state-of-the-art care. Recently, Hines sent a prosthetist with me to Florida to learn 

about the high-tech artificial legs that I obtain from the private practitioner there. 

He was overwhelmed by the technology and the civilian practitioner was appalled 

at the lack of current knowledge shown by the Hines representative. The USDVA 

is absolutely not ready to treat amputee patients at the high-tech levels set at the 

DOD medical facilities. Much of the technology is expensive and most of the VA personnel are not trained on equipment that has been on the market for several years, 

let alone the state-of-the-art innovations that occur almost monthly in this field. I 

recommend that the VA expand its existing program that allows patients to access 

private prosthetic practitioners. There is simply not enough time for USDVA to 

catch up in this field in time to adequately serve the new amputees from OIF/OEF 

during these critical first 2 years following amputation. Perhaps after the end of the 

current wars in Iraq and Afghanistan, the VA will have time to advance its prosthetics program. 

I’ve appeared before both the U.S. Senate Committee on Veterans’ Affairs and the 

House Subcommittee on Veterans’ Affairs to testify on the seamless transition from 

DOD to VA health care and have presented several recommendations to improve the 

health care services for our Nation’s Veterans. For instance, I recommended that 

any seamless transition program must also include comprehensive screening for 

Traumatic Brain Injury (TBI), Post Traumatic Stress Disorder (PTSD) and vision 

loss by both the DOD and the USDVA Health Care systems. 

42

I want to highlight how Illinois is addressing TBI and PTSD. Over the past summer, Illinois announced the Nation’s first-of-its-kind program to screen every Illinois 

National Guard member for Traumatic Brain Injury while offering free TBI screening to all other Illinois Veterans. As part of this program, Illinois is also establishing a24-hour, toll-free hotline to provide psychological assistance to Veterans 

suffering from Post Traumatic Stress Disorder. When a Veteran calls this hotline, 

a clinician performs an initial over-the-phone screening and determines the next 

steps to take. All staff will be trained in the area of combat-related PTSD and other 

mental issues faced by Veterans, and there is at least one psychiatrist on call at 

all times. The hotline format is important, as our Veterans often do not have the 

option or willingness to drive 100 miles for PTSD treatment. When one wakes up 

from a nightmare at 2 a.m. on a Friday night, one needs help immediately, not at 

8 a.m. on the following Monday, which is the current case with the USDVA. I know 

that efforts are underway to strengthen these assessments by both the DOD and 

the USDVA. However, there is no standard procedure in place to insure that all returning servicemembers are screened nation-wide. 

I commend this panel for its oversight of the U.S. Veterans Administration and 

the facilities that it operates. We should all demand that our Veterans have access 

to care that is commensurate to their dedication to our country.

I would be happy to take any questions.

Senator AKAKA [Presiding]. Thank you. 

Mr. McCarty? 

STATEMENT OF STEVEN MCCARTY, VETERAN, OPERATION 

IRAQI FREEDOM, BEDFORD, TEXAS 

Mr. MCCARTY. Mr. Chairman, thank you for the opportunity to 

testify today before the Veterans’ Affairs Committee. I look forward 

to sharing my story with the Senators here this morning. 

My name is Steve McCarty, and I am a Lance Corporal with the 

United States Marine Corps Reserve with the 14th Marines Headquarters Battery out of Fort Worth, Texas. On June 1, 2006, I was 

part of a detachment that was activated with 1st Marines 24th Division. We were sent to Fallujah, Iraq, from September 24, 2006, 

to April 15, 2007. During this time I served as a member of a truck 

platoon. 

In February of this year, while I was still in Iraq, I was concerned when I started experiencing diarrhea with blood in the 

stool. When I confronted my corpsman, he gave me the option to 

either keep going and do the missions or go to medical and receive 

treatment and possibly miss operations. I chose to keep going. 

Upon returning from Iraq in April, the stress of demobilization 

and jubilation of getting reacquainted with family and civilian life 

overshadowed the discomfort of my symptoms, which seemed minor 

at the time. While driving home from visiting my grandmother in 

Indiana, my symptoms got to the state where they could no longer 

be ignored. I was in severe pain, had bad diarrhea, and was vomiting. My parents were now aware of my deteriorating health and 

convinced me to stop at the VA Hospital in Marion, Illinois. 

Upon arriving at the emergency room, the doctor ran various 

tests, which included blood work and a CAT scan. The results of 

these tests were negative. At this time, the ER doctor, who was a 

surgeon, admitted me and diagnosed my symptoms as possibly 

being appendicitis. He recommended removing the appendix and 

doing exploratory surgery. After he consulted with other doctors, 

some of which did not agree with this diagnosis, he took the advice 

of a second surgeon who recommended doing the surgery 

laparoscopically. We were more comfortable with this technique 

43

due to the shorter recovery time and lack of a large incision. The 

doctors thought I would be ready to leave the hospital in a few 

days. 

I had surgery at the Marion VA on Friday, June 15th. After the 

operation, we were told that the appendix did not look as bad as 

what they anticipated. Although I had been suffering for 4 months, 

the surgeon thought I must have a virus since the antibiotics were 

not having any effect. 

On Sunday, 2 days after the surgery, my symptoms were getting 

worse. However, the doctors continued to follow the timetable and 

release after having your appendix removed. At this point one of 

the nurses told my parents that she would get me out of there if 

I were her son. She said the doctors did not know what was wrong 

with me. 

Seeing my deterioration, my parents began asking for specialists 

on Monday, June 18. They were told the specialists were part of 

the clinic and were not available to attend to hospital patients. 

After receiving outside advice, my parents spoke with the patient 

advocate at the hospital. We were told that there was not a gastroenterologist, but an infectious disease specialist was available. 

Four days after my surgery, my stomach still swollen and the 

other symptoms still there, an infectious disease specialist finally 

came to see me. Within minutes, he diagnosed me with dysentery 

and changed my antibiotic, but he could not explain my swollen 

stomach. I honestly looked like I was 9 months pregnant. That 

night my mom asked a nurse about this, and she said she had 

never seen it last this long. Another nurse told us that she would 

never take her family to any doctors there. They go to doctors in 

St. Louis, Missouri—a 2-hour drive from Marion. 

After 7 days at the Marion hospital, my condition had stabilized 

enough for me to attempt to travel, and my parents asked for assistance in getting me quickly and safely home. The only assistance 

given to us was the cost of one ticket for the shuttle that runs from 

Marion to the St. Louis airport. When I was discharged, I was supposed to take the new antibiotic, but they mistakenly gave me the 

old and less effective one. 

Upon returning home to Texas, my close Marine buddy informed 

us that we still had TRICARE coverage. The morning after returning from Illinois, we went to the emergency room at Harris Methodist H-E-B Hospital. The doctor noticed the severity of my symptoms and did all the same tests I had received at Marion. Upon reviewing the test results, the ER doctor discovered that my colon 

was perforated and I had free air under my diaphragm. My waste 

was pouring into my abdominal cavity. The ER doctor immediately 

called in the specialists. 

I was taken to surgery that afternoon. Two sections of my colon 

had to be removed. These two sections were in the same location 

as two of the laparoscopic incisions. Due to the severity of the infection, my wound had to be left open. After the surgery, the doctor 

told my parents I was lucky to be alive. If it had not been for the 

fact that I was in such good shape and young, I would be dead. 

I spent the next 3 weeks in the hospital and was discharged on 

July 11, 2007. I was attached to a wound vac for 6 weeks. Now I 

have both a colostomy and ileostomy bag. The doctors at Harris 

44

Methodist H-E-B Hospital finally diagnosed my symptoms I had 

been experiencing since my service in Iraq as ulcerative colitis—a 

condition that would have been seen earlier if a colonoscopy would 

have been performed. 

This has affected the quality of life for me and my family. This 

has prevented me from drawing unemployment and working. It is 

also hindering my advancement in the military. I have no source 

of income, and I am told it will take 1 year for the VA to process 

my disability requests. I have applied for incapacity pay, but have 

not received anything to date. 

In closing, I have a colostomy bag, an ileostomy bag, a large open 

wound, and multiple laparoscopic incisions. I will be unable to effectively serve in the Marines at home as well as unable to deploy. 

The actions of the VA hospital in Marion have removed this Marine 

and countless other veterans from the war on terror. These wounds 

are not a result of insurgents; they are a result of incompetence on 

American soil. 

Thank you for allowing me to share my story today. I am happy 

to answer any questions about my experience. 

[The prepared statement of Mr. McCarty follows:]

PREPARED STATEMENT OF STEVEN MCCARTY, VETERAN, OPERATION IRAQI FREEDOM

Mr. Chairman, thank you for the opportunity to testify today before the Veterans’ 

Affairs Committee. I look forward to sharing my story with the Senators here this 

morning. 

My name is Steve McCarty and I am a Lance Corporal in the U.S. Marine Corps 

Reserve with the 14th Marines Headquarters Battery out of Fort Worth, Texas. On 

June 1, 2006, I was part of a detachment that was activated with 1st Marines 24th 

Division. We were sent to Fallujah, Iraq from September 24, 2006, through April 

15, 2007. During this time I served as a member of a truck platoon, primarily driving a 7&fxsp0;-ton refueling truck. 

In February of this year, while I was still in Iraq, I was concerned when I started 

experiencing diarrhea with blood in the stool. My symptoms were consistent with 

what has since been diagnosed as ulcerative colitis. When I confronted my corpsman, he gave me the option to either keep going and do the missions or go to medical and receive treatment and possibly miss operations. I chose to keep going. 

Upon returning from Iraq in April, the stress of demobilization and jubilation of 

getting reacquainted with family and civilian life overshadowed the discomfort of 

my symptoms which seemed minor at the time. After being deactivated off of active 

duty on June 1, my family and I traveled to the Midwest. While driving home from 

visiting my grandmother in Indiana, my symptoms got to the state where they could 

no longer be ignored. I was in severe pain, had bad diarrhea, and was vomiting. 

My parents were now aware of my deteriorating health and convinced me to stop 

at the VA Hospital in Marion, Illinois. 

Upon arriving at the emergency room, the doctor ran various tests which included 

blood work and a CAT scan. The results of these tests were negative. At this time, 

the ER doctor, who was a surgeon, admitted me and diagnosed my symptoms as 

possibly being appendicitis. He recommended removing the appendix and doing exploratory surgery. After he consulted with other doctors, some of which did not 

agree with the diagnosis, he took the advice of a second surgeon who recommended 

doing the surgery laparoscopically. We were more comfortable with this technique 

due to the shorter recovery time and lack of a large incision. The doctors thought 

I would be ready to leave the hospital in a few days. 

I had surgery at the Marion VA on Friday, June 15. After the operation, we were 

told that the appendix did not look as bad as they had anticipated. Although I had 

been suffering for 4 months, the surgeon thought I must have a virus since the antibiotics were not having any effect. 

On Sunday, 2 days after the surgery, my symptoms were getting worse. In addition, my stomach was now swollen. However, the doctors continued to follow the 

timetable for recovery and release after having appendicitis. At this point one of the 

nurses told my parents that she would get me out of there if I were her son. She 

said the doctors did not know what was wrong with me. 

45

Seeing my deterioration, my parents began asking for specialists on Monday, June 

18. They were told the specialists were part of the clinic and were not available to 

attend to hospital patients. After receiving outside advice, my parents spoke with 

the patient advocate at the hospital. We were told there was not a gastroenterologist, but an infectious disease specialist was available. 

Four days after my surgery, my stomach still swollen and the other symptoms 

still there, an infectious disease specialist finally came to see me. Within minutes, 

he diagnosed me with dysentery and changed my antibiotic, but he could not explain 

my swollen stomach. I honestly looked like I was 9 months pregnant. That night 

my mom asked a nurse about this and she said she had never encountered a situation like this. Another nurse told us that she would never take her family to any 

doctors there. She goes to doctors in St. Louis, Missouri—a 2-hour drive from Marion. 

After 7 days at the Marion VA, my condition had stabilized enough for me to attempt to travel and my parents asked for assistance in getting me quickly and safely home. The only assistance given was the cost of one ticket for the shuttle that 

runs from Marion to the St. Louis airport. When I was discharged, I was supposed 

to take the new antibiotic with me but they mistakenly gave me the old and less 

effective one. 

Upon returning home to Texas, my close Marine buddy informed us that we still 

had TRICARE. The morning after returning from Illinois, we went to the emergency 

room (ER) at Harris Methodist H-E-B Hospital. The doctor noticed the severity of 

my symptoms and did the same tests I had received in Marion. Upon reviewing the 

test results, the ER doctor discovered that my colon was perforated and I had free 

air under my diaphragm. My waste was actually pouring into my abdominal cavity. 

The ER doctor immediately called the specialists. 

I was taken to surgery that afternoon. Two sections of my colon had to be removed. Those two sections were in the same location as two of the laparoscopic incisions. Due to the severity of the infection, the wound had to be left open. After the 

surgery, the doctor told my parents I was lucky to be alive. If I hadn’t been in such 

good shape and young, I would be dead. 

I spent the next 3 weeks in the hospital and was discharged on July 11, 2007. 

I celebrated my birthday while still in the hospital. I was attached to a wound vac 

for 6 weeks. I now have both a colostomy bag and ileostomy bag. The doctors at 

Harris Methodist H-E-B Hospital finally diagnosed the symptoms I had been experiencing since my service in Iraq as ulcerative colitis. The part of my colon that remains is not functional at this time. 

This has affected the quality of life for me and my family. This has prevented me 

from drawing unemployment and working. It is also hindering my advancement in 

the military. I have no source of income and I am told it will take 1 year for the 

VA to process my disability requests. I have also applied for incapacity pay but have 

not received anything to date. 

In closing, I have a colostomy bag, an ileostomy bag, a large open wound, and 

multiple laparoscopic incisions. I will be unable to effectively serve in the Marines 

at home as well as unable to deploy. The actions of the VA hospital in Marion have 

removed this Marine and countless other veterans from the war on terror. These 

wounds are not a result of insurgents, they are a result of incompetence on American soil.

Thank you for allowing me to share my story today. I am happy to answer questions about my experience.

Senator AKAKA. Thank you, Mr. McCarty. 

Senator Durbin? 

Senator DURBIN. I would like to thank Chairman Akaka for allowing me to ask first. I have to go down to a Senate Judiciary 

Committee meeting. My thanks to the panel, each one of you. 

First, to Lance Corporal McCarty, who came by my office yesterday with his family, this is a heart-breaking story of a young man 

with a medical problem whose treatment was inappropriate and 

which led to complications, pain, hospitalization, and your life has 

changed. That is the reality when serious mistakes are made. I am 

certain that your case will be investigated, as it should be, and I 

stand ready to help you in any way that I can. You served your 

country. Now we need to serve you. And thank you for being here 

today and telling your story. I know it was not easy, but it is imVerDate 0ct 09 2002 14:37 May 20, 2008 Jkt 000000 PO 00000 Frm 00049 Fmt 6633 Sfmt 6601 H:\PS41451\DOCS\41911.TXT SENVETS PsN: PAULIN
46

portant that it be heard. It is a reminder that a lot of things that 

we are talking about here involve real human lives, the lives and 

the futures of our veterans like Steven McCarty. So, thank you so 

much for being here. 

To Tammy Duckworth, let me just say that there are probably 

very few people in America better qualified than you to talk about 

the treatment of soldiers and veterans after your experience serving in Iraq and coming back and facing rehabilitation since then. 

I am so happy that you are here today and that you continue to 

serve your Nation and my State of Illinois. I could not agree with 

you more on the basic premise that if we cannot provide the medical care promised to Steven McCarty and every other soldier, regardless of the war they served in or the time that they served, 

then we need to consider alternatives. And I have seen it repeatedly. This morning, as I came in here, I met Eric Edmondson on 

the sidewalk, a man that you know, Tammy, and I know well. It 

is a long and heroic story of his family fighting for his rights. This 

man, a victim of Traumatic Brain Injury in Iraq, has made dramatic strides because of the determination of his family. 

When I think of what he went through and I hear Lance Corporal McCarty talk about waiting a year—a year?—to have his disability claim processed. What is wrong with this picture? We are 

telling recruits if you will show up in 6 weeks we will give you 

more money to go overseas. And now we tell them when they return wounded, wait a year before we can tell you what your Government is going to provide? This is totally unfair, and something 

has to be done about it. 

Mr. Williamson, you heard some of the questions earlier that 

were asked about this situation between Massachusetts and the 

Marion VA, and from what we gathered, Massachusetts really did 

not want to tell the Marion VA much about this Dr. Mendez and 

his giving up his right to practice medicine in Massachusetts. During the course of your GAO investigation, did you come across anything like this? 

Mr. WILLIAMSON. No, we did not, Senator. We looked at a sample 

of cases at each of the seven facilities we visited and we did not 

come across anything like this. 

Senator DURBIN. It seems to me to make a mockery of 

recredentialing if the individual veterans facility cannot get 

straight and complete answers about the status of licensure of one 

of their medical staff. How could you possibly know whether that 

person should continue practicing? Did you make any recommendations about that in terms of your VA study? 

Mr. WILLIAMSON. Well, our recommendations dealt with privileging, and really, I think from what I have heard today, that was 

what VA is focusing on. The credentialing process for the seven 

hospitals that we looked at, was following VA requirements. However, privileging, was an area we found that needed some improvements. We have not compared VA’s credentialing and privileging 

process with that of the private sector. VA’s got a good system. But 

the system is only as good as the people implementing it, and I 

really want to say that I think it is important to wait for the VA 

IG’s report to come out to see whether it was the process or was 

it the implementation of that process. 

47

Senator DURBIN. I completely agree with you on that. But I tell 

you, one thing that came out today is the fact that of the 34,000 

medical professionals who are being reviewed—I think that number 

is correct—some 17,000 of them are requiring some follow-up, additional information, which is an indication to me that the system 

needs to be a lot more thorough and a lot more complete than it 

currently is. And I think your GAO study may have pointed some 

new directions for us to move in that regard. 

Mr. Chairman, I am going to have to leave for the Judiciary 

Committee. I want to thank this panel. Steven, thank you and your 

family for the sacrifice you made to be here. And, Tammy, I am 

looking forward to continuing to work with you in Illinois and beyond. Mr. Williamson, thank you for your insight on this. 

I hope, Mr. Chairman, when this investigation is completed at 

Marion, that we might schedule another hearing to see what lessons can be learned. Thank you very much. 

Senator AKAKA. Thank you very much, Senator Durbin. We will 

look very closely at the results of the IG investigation. Thanks so 

much. 

Mr. McCarty, again, I appreciate your coming forward as you 

have, and I want you to know how sorry we are about what happened to you. I hope that your claim for VA benefits will be resolved quickly. Please let me know if I can be of assistance in helping to resolve this effort. 

At this time I just want to ask whether you have any other comments, besides the testimony you have made concerning your experiences, and especially what you hope for—what the VA can possibly do for you. 

Mr. MCCARTY. At this time, Mr. Chairman, I want to thank you 

again for the opportunity to speak today. The only thing that I can 

see that I would like to come out of this is the doctors at the VA 

are held accountable for their performance. That is really the only 

thing that I would like to be done. 

Senator AKAKA. Well, thank you for that. You know that the 

focus in this hearing has been to that end—to be sure that we can 

continue quality control. 

Ms. Duckworth, talking about quality control—and as I mentioned, this is part of the reason for this hearing—what type of 

quality assurance does your office do working in conjunction with 

the Division of Professional Regulation to ensure that veterans in 

your State receive the highest standard of care? 

Ms. DUCKWORTH. Well, sir, we have no say over the Federal VA 

facilities, in our case Hines, Marion, and Danville. All we can do 

is, as we get complaints into our office, refer them to the local hospital administrator and bring it to their attention. So, we actually—as a State agency—have no say over the Federal. 

We are, however, as a State agency, inspected by the Federal VA 

as well as the State of Illinois Department of Public Health. So our 

four veterans’ homes that we operate in the State of Illinois are 

double inspected, not only by the Federal VA when they come out 

and inspect our facilities, but also by our sister agency. And I think 

that double inspection process, while it can be onerous at times, it 

helps us to have a checks and balance as to the entire process. And 

48

oftentimes we have found that our sister agency is much tougher 

on us in terms of their findings than the Federal VA has been. 

I do want to say, sir, that I have had personally wonderful treatment through the VA system. I think that Hines VA, with its blind 

rehabilitation program, with its spinal cord injury program, really 

leads the Nation and that the VA has great expertise that we need 

to respect and maximize. However, I do think that there is opportunity here for us to look at some outside care and more participation of local communities, teaching hospitals, that sort of thing, to 

not supplant, but supplement the Federal VA. And I think that 

bringing in some outside—as I mentioned earlier, requiring doctors 

to have privileges at the local hospital where the VA hospital is 

also co-located—will help with that process. 

So, as far as the State of Illinois is concerned, we are co-inspected by our sister agency in the State of Illinois. We are also 

inspected federally. We have no say whatsoever over the Federal 

VA other than getting complaints and letters and trying to advocate for our veterans the best that we can. 

Senator AKAKA. Speaking about Marion, when was your office 

told by VA about the spike in deaths at Marion? 

Ms. DUCKWORTH. I have never received official notice from the 

Federal VA, sir. We have a veterans’ home in Anna, in far southern 

Illinois, which sends its patients to Marion VA. The only notice we 

received was that we could no longer send our patients there for 

surgeries, and we have never been informed as to what the reason 

was other than just through the media and me making some phone 

calls. 

Senator AKAKA. I want to thank you for your remarks about VA 

having the best kind of providers. 

Ms. DUCKWORTH. Yes, sir. 

Senator AKAKA. Unfortunately, you know, there are many clinics, 

many hospitals, and our effort here is to try to maintain quality 

control throughout the system. And your testimony and your responses will help us do that, and I am sure will help the administration do it as well. We are looking forward to continuing this 

until the investigation is done. 

Mr. Williamson, as may have been the situation in the case of 

the surgeon at Marion, timing clearly poses a problem in the process of background checks. Because medical administrators cannot 

discuss open disciplinary investigations, employers may not be 

aware of serious issues surrounding potential hires. My question to 

you is: How can the background-checking process be improved to 

avoid this problem? 

Mr. WILLIAMSON. Well, as you may know, Mr. Chairman, we did 

work in 2004 and 2006 on screening of all health care practitioners 

in VA. We took issue with the background processes in the sense 

that in many cases they were not being done, and there was not 

adequate documentation to show, in some cases, that the results of 

the background investigation had been reviewed. 

Since that time, VA has implemented some stricter backgroundchecking procedures; whereby, they are now doing background 

checks on all their health care providers, and they now have a 

process in place to document that. So, I think with the fingerprintonly kinds of background checks that are going on, I think VA is 

49

now doing those kind of things that we took issue with in earlier 

work. 

Senator AKAKA. Mr. Williamson, what can be done to lessen the 

chances that Marion will be repeated? 

Mr. WILLIAMSON. I am going to go back to what I said a minute 

ago, Mr. Chairman, and that is that the process can be a good one, 

but it really needs to be followed. And I really cannot comment on 

the Marion situation. I just do not know the facts and, pending the 

VA IG review, I think it would be remiss if I commented on that. 

But I can tell you that I have worked for GAO for over 40 years, 

and in that time I have looked at hundreds—done hundreds and 

hundreds of audits, many of those something like this, where something has gone wrong. And in a general sense, without reflecting 

on Marion, I can tell you that there are always—almost always—

danger signals that if in 20/20 hindsight people would have paid 

attention to, we could have prevented these kind of things. 

So I would be, I think, as curious as this Committee is in terms 

of trying to find out what the causes of the Marion situation were. 

Senator AKAKA. Yes. It is interesting. When you raise ‘‘dangerous 

signals,’’ it is something that I hope we can deal with, because it 

is important and it is the beginning of something that we need to 

know more about. And with your 40 years of experience with GAO, 

I hope you can come up with a solution to that, so that we can do 

it here in our Government. 

But all of this, of course, would be done for the purpose of keeping quality control throughout our system. As was mentioned, 

when you talk about 56,000 doctors, it is huge; and to keep control 

over the 56,000 is very difficult. But we have to do that, try our 

best to do that, and this is our effort today. 

So thank you so much, all of you, for your testimonies and for 

your responses, and I want to wish you well. Remember, we are 

here to maintain that high quality of service to our veterans, and 

that is what we are doing. 

Thank you very much, and this hearing is adjourned. 

[Whereupon, at 11:10 a.m., the Committee was adjourned.] 

(51)

A P P E N D I X 

PREPARED STATEMENT OF THE AMERICAN ACADEMY OF PHYSICIAN ASSISTANTS

On behalf of the nearly 65,000 clinically practicing physician assistants (PAs) in 

the United States, the American Academy of Physician Assistants (AAPA) is pleased 

to submit comments for the hearing record on Hiring Practices and Quality Control 

in VA Medical Facilities. The Academy’s comments will focus on H.R. 2790, a bill 

introduced in the House by Representatives Phil Hare and Jerry Moran to amend 

title 38, United States Code, to establish the position of Director of Physician Assistant Services within the office of the Under Secretary of Veterans’ Affairs for Health. 

AAPA believes that enactment of H.R. 2790 is essential to improving patient care 

for our Nation’s Veterans, ensuring that the 1,600 PAs employed by the VA are fully 

utilized and removing unnecessary restrictions on the ability of PAs to provide medical care in VA facilities. The Academy believes that enactment of H.R. 2790 is necessary to advance recruitment and retention of PAs within the Department of Veterans’ Affairs and requests that the Senate Committee on Veterans’ Affairs supports 

this important legislation. 

Physician assistants are licensed health professionals, or in the case of those employed by the Federal Government, credentialed health professionals, who—

• practice medicine as a team with their supervising physicians • exercise autonomy in medical decisionmaking • provide a comprehensive range of diagnostic and therapeutic services, including 

performing physical exams, taking patient histories, ordering and interpreting laboratory tests, diagnosing and treating illnesses, suturing lacerations, assisting in 

surgery, writing prescriptions, and providing patient education and counseling • may also work in educational, research, and administrative settings.

Physician assistants’ educational preparation is based on the medical model. PAs 

practice medicine as delegated by and with the supervision of a physician. Physicians may delegate to PAs those medical duties that are within the physician’s scope 

of practice and the PA’s training and experience, and are allowed by law. A physician assistant provides health care services that were traditionally only performed 

by a physician. All states, the District of Columbia, and Guam authorize physicians 

to delegate prescriptive privileges to the PAs they supervise. AAPA estimates that 

in 2006, approximately 231 million patient visits were made to PAs and approximately 286 million medications were prescribed or recommended by PAs. 

The PA profession has a unique relationship with veterans. The first physician 

assistants to graduate from PA educational programs were veterans—former medical corpsmen who had served in Vietnam and wanted to use their medical knowledge and experience in civilian life. Dr. Eugene Stead of the Duke University Medical Center in North Carolina put together the first class of PAs in 1965, selecting 

Navy corpsmen who had considerable medical training during their military experience as his students. Dr. Stead based the curriculum of the PA program in part on 

his knowledge of the fast-track training of doctors during World War II. Today, 

there are 139 accredited PA educational programs across the United States. Approximately 1,600 PAs are employed by the Department of Veterans Affairs, making 

the VA the largest single employer of physician assistants. These PAs work in a 

wide variety of medical centers and outpatient clinics, providing medical care to 

thousands of veterans each year. Many are veterans themselves. 

Physician assistants are fully integrated into the health care systems of the 

Armed Services and virtually all other public and private health care systems. PAs 

are on the front line in Iraq and Afghanistan, providing immediate medical care for 

wounded men and women of the Armed Forces. Within each branch of the Armed 

Services, a Chief Consultant for PAs is assigned to the Surgeon General. PAs are 

covered providers in TRICARE. In the civilian world, PAs work in virtually every 

area of medicine and surgery and are covered providers within the overwhelming 

52

majority of public and private health insurance plans. PAs play a key role in providing medical care in medically underserved communities. In some rural communities, a PA is the only health care professional available. 

AAPA is very appreciative of the leadership of many Members of the Senate Committee on Veterans’ Affairs in creating the VA’s Physician Assistant (PA) Advisor 

to the Under Secretary for Health. The current PA Advisor to the Under Secretary 

for Health was authorized through section 206 of P.L. 106–419 and has been filled 

as a part-time, field position. Prior to that time, the VA had never had a representative within the Veterans Health Administration with sufficient knowledge of the PA 

profession to advise the Administration on the optimal utilization of PAs. This lack 

of knowledge resulted in an inconsistent approach toward PA practice, unnecessary 

restrictions on the ability of VA physicians to effectively utilize PAs, and an underutilization of PA skills and abilities. The PA profession’s scope of practice was not 

uniformly understood in all VA medical facilities and clinics, and unnecessary confusion existed regarding such issues as privileging, supervision, and physician 

countersignature. 

Although the PAs who have served as the VA’s part-time, field-based PA Advisor 

have made progress on the utilization of PAs within the agency, there continues to 

be inconsistency in the way that local medical facilities use PAs. In one case, a local 

facility decided that a PA could not write outpatient prescriptions, despite licensure 

in the state allowing prescriptive authority. In other facilities, PAs are told that the 

VA facility can not use PAs and will not hire PAs. These restrictions hinder PA employment within the VA, as well as deprive veterans of the skills and medical care 

PAs have to offer. 

The AAPA believes that a full-time Director of PA Services within the VA Central 

Office is necessary to recruit and retain PAs in the Department of Veterans’ Affairs. 

PAs are in high demand in the private market place.

• The US Bureau of Labor Statistics (BLS) projects that the number of PA jobs 

will increase by 50 percent between 2004 and 2014 and has ranked the profession 

as the fourth fastest growing profession in the country. 

• US News and World Report named the PA profession within its 2007 list of 25 

best careers. 

• Money magazine ranked the PA profession No. 5 in its 2006 list of top careers; 

CNN listed the PA profession as No. 4 in its 2006 list of top US careers.

The growth in PA jobs is in the private sector, not the Federal Government. AAPA 

believes that the Federal Government, including the Department of Veterans’ Affairs, will not be able to compete with the private market unless special efforts are 

made to recruit and retain PAs. According to the AAPA’s 2006 Census Report, an 

estimated 3,545 PAs are employed by the Federal Government to provide medical 

care. Unfortunately, AAPA’s Annual Census Reports of the PA Profession from 1997 

to 2006 document an overall decline in the number of PAs who report Federal Government employment. In 1991, nearly 13.4 percent of the total profession was employed by the Federal Government. This percentage dropped to 6 percent in 2006. 

The Academy also believes that the elevation of the PA Advisor to a full-time Director of Physician Assistant Services, located in the VA central office, is necessary 

to increase veterans’ access to quality medical care by ensuring efficient utilization 

of the VA’s PA workforce in the Veterans Health Administration’s patient care programs and initiatives. PAs are key members of the Armed Services’ medical teams 

but are an underutilized resource in the transition from active duty to veterans’ 

health care. As health care professionals with a longstanding history of providing 

care in medically underserved communities, PAs may also provide an invaluable 

link in enabling veterans who live in underserved communities to receive timely access to quality medical care. 

Thank you for the opportunity to submit a statement for the hearing record in 

support of legislation to elevate the VA’s PA Advisor to a full-time position in the 

VA’s central office. AAPA is eager to work with the Senate Committee on Veterans’ 

Affairs to improve the availability and quality of medical care to our Nation’s veteran population.

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