U.S. GOVERNMENT PUBLISHING OFFICE

30–370 WASHINGTON : 2018

MAXIMIZING ACCESS AND RESOURCES: AN EXAMINATION OF VA PRODUCTIVITY AND EFFICIENCY 

HEARING 

BEFORE THE

SUBCOMMITTEE ON HEALTH 

OF THE

COMMITTEE ON VETERANS’ AFFAIRS 

U.S. HOUSE OF REPRESENTATIVES 

ONE HUNDRED FIFTEENTH CONGRESS 

FIRST SESSION 

THURSDAY, JULY 13, 2017 

Serial No. 115–24 

Printed for the use of the Committee on Veterans’ Affairs 

( 

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

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(II) 

COMMITTEE ON VETERANS’ AFFAIRS 

DAVID P. ROE, Tennessee, Chairman 

GUS M. BILIRAKIS, Florida, Vice-Chairman 

MIKE COFFMAN, Colorado 

BRAD R. WENSTRUP, Ohio 

AMATA COLEMAN RADEWAGEN, American 

Samoa 

MIKE BOST, Illinois 

BRUCE POLIQUIN, Maine 

NEAL DUNN, Florida 

JODEY ARRINGTON, Texas 

JOHN RUTHERFORD, Florida 

CLAY HIGGINS, Louisiana 

JACK BERGMAN, Michigan 

JIM BANKS, Indiana 

JENNIFFER GONZALEZ-COLON, Puerto 

Rico 

TIM WALZ, Minnesota, Ranking Member 

MARK TAKANO, California 

JULIA BROWNLEY, California 

ANN M. KUSTER, New Hampshire 

BETO O’ROURKE, Texas 

KATHLEEN RICE, New York 

J. LUIS CORREA, California 

KILILI SABLAN, Northern Mariana Islands 

ELIZABETH ESTY, Connecticut 

SCOTT PETERS, California 

JON TOWERS, Staff Director 

RAY KELLEY, Democratic Staff Director 

SUBCOMMITTEE ON HEALTH 

BRAD WENSTRUP, Ohio, Chairman 

GUS BILIRAKIS, Florida 

AMATA RADEWAGEN, American Samoa 

NEAL DUNN, Florida 

JOHN RUTHERFORD, Florida 

CLAY HIGGINS, Louisiana 

JENNIFER GONZALEZ-COLON, Puerto Rico 

JULIA BROWNLEY, California, Ranking 

Member 

MARK TAKANO, California 

ANN MCLANE KUSTER, New Hampshire 

BETO O’ROURKE, Texas 

LUIS CORREA, California 

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

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

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

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

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

is further refined. 

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(III) 

C O N T E N T S 

Thursday, July 13, 2017 

Page 

Maximizing Access And Resources: An Examination Of VA Productivity And 

Efficiency ............................................................................................................... 1 

OPENING STATEMENTS 

Honorable Brad Wenstrup, Chairman ................................................................... 1 

Honorable Julia Brownley, Ranking Member ....................................................... 2 

WITNESSES 

C. Sharif Ambrose, Principal, Grant Thornton LLP ............................................. 4 

Prepared Statement ......................................................................................... 21 

Randall B. Williamson, Director, Health Care, Government Accountability 

Office ..................................................................................................................... 5 

Prepared Statement ......................................................................................... 24 

Jonathan B. Perlin MD, PhD, President, Clinical Services Group, Chief Medical Officer, HCA Healthcare, Inc. ...................................................................... 6 

Prepared Statement ......................................................................................... 28 

Carolyn Clancy M.D., Deputy Under Secretary for Organizational Excellence, 

Veterans Health Administration, U.S. Department of Veterans Affairs ......... 8 

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

Accompanied by: 

Murray D. Altose M.D., Chief of Staff, Louis Stokes Cleveland VA Medical Center, Veterans Integrated Service Network 10, Veterans 

Health Administration, U.S. Department of Veterans Affairs 

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(1) 

MAXIMIZING ACCESS AND RESOURCES: AN 

EXAMINATION OF VA PRODUCTIVITY AND 

EFFICIENCY 

Thursday, July 13, 2017 

U.S. HOUSE OF REPRESENTATIVES, 

COMMITTEE ON VETERANS’ AFFAIRS, 

SUBCOMMITTEE ON DISABILITY ASSISTANCE

AND MEMORIAL AFFAIRS, 

Washington, D.C. 

The Subcommittee met, pursuant to notice, at 2:02 p.m., in Room 

334, Cannon House Office Building, Hon. Brad Wenstrup [Chairman of the Subcommittee] presiding. 

Present: Representatives Wenstrup, Bilirakis, Radewagen, Dunn, 

Rutherford, Higgins, Brownley, Takano, Kuster, and Correa. 

Also Present: Representative Roe. 

OPENING STATEMENT OF BRAD WENSTRUP, CHAIRMAN 

Mr. WENSTRUP. The Subcommittee will come to order. Good 

afternoon and thank you all for joining us for today’s hearing, 

‘‘Maximizing Access and Resources: An Examination of VA Productivity and Efficiency.’’ 

Today, we will discuss clinical productivity and efficiency in the 

Department of Veterans Affairs’ health care system. As a clinician 

and a veteran, this is an issue I hold near and dear to my heart. 

As one of our witnesses, the Government Accountability Office, will 

note this afternoon, VHA’s bottom line has grown significantly over 

the last decade, increasing from $37.8 billion in fiscal year 2006 to 

$91.2 billion in fiscal year 2016. 

As a Federal agency, VA has an obligation to be a responsible 

steward of the taxpayer dollars that so generously fill its coffers. 

As the Federal agency responsible for providing health care to our 

Nation’s veterans, VA has an obligation to be a responsible servant 

worthy of caring for the greatest fighting force the world has ever 

known. 

However, it is not clear whether or not the increasing amount of 

money that has been allocated to VHA has resulted in a more productive, efficient health care system or in veteran care that is more 

accessible, more high quality, or more cost effective, and that is our 

goal. 

This afternoon, we are going to examine findings from both a recent GAO report and from the 2015 independent assessment, which 

will detail a variety of concerns with clinical efficiency and provider 

productivity at VA medical facilities. 

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For example, we are going to hear how the current models and 

metrics at VHA uses to assess clinical efficiency and provider productivity failed to account for all providers and services, failed to 

accurately reflect the intensity of clinical workloads and staffing 

levels, and may be populated with inaccurate data, as well as how 

VA central office policies and procedures failed to provide sufficient 

monitoring and oversight, even when problems have been identified. 

We will also discuss how VHA’s productivity compares to leading 

private sector health care systems and what industry best practices 

VHA may be able to use to increase quality and efficiency. For example, we are going to hear that the number of patients assigned 

to VHA primary care providers is 12 percent lower than the private 

sector benchmark for patients of a similar acuity, which all begs 

the question, what are we paying for? 

To be clear, VHA is taking strides in making progress, and not 

all of the barriers to increased productivity and efficiency are under 

the control of the individual VA medical facilities or providers. As 

we discussed during yesterday’s Full Committee hearing on VA’s 

capital asset deficiencies, the average VA medical facility building 

is five times older than the average building in a not-for-profit hospital system in the United States and is not well situated to the 

provision of high quality care or to efficient practice of medicine in 

the 21st century. 

As a doctor myself, I know firsthand the constraints that are 

placed on a provider who lacks sufficient clinical space and adequate support staff. In the private sector, room-to-provider ratios 

are typically 3 or 4 to 1. In the VA health care system, providers 

typically only have a 1-to-1 room-to-provider a ratio, as well as significantly fewer nurses and administrative staff. So that means, in 

many cases, the deck is stacked against a VA doctor the second 

they step into their clinic. 

We need to find solutions for those providers, for the taxpayers 

whose hard-earned dollars are supporting VA’s massive bureaucracy in increasing frequency and, most importantly, for the veterans who deserve a more efficient, accessible VA health care system. 

I will now yield to Ranking Member Brownley for any opening 

statement that she may have. 

OPENING STATEMENT OF JULIA BROWNLEY, RANKING 

MEMBER 

Ms. BROWNLEY. Thank you, Mr. Chairman. 

Paired alongside yesterday’s hearing on capital asset management, the topic of VHA productivity and efficiency is both timely 

and vital as we discuss VHA’s ability to care for our Nation’s veterans in the future. 

Yesterday, former Secretary Principi stated he did not believe VA 

would survive another decade of capital asset constraints on the 

scale we see now. I could not help but think of how this issue of 

provider productivity and efficiency ties directly into the issues we 

see with capital asset management at the VA. 

As Ranking Member Walz and Chairman Wenstrup mentioned in 

yesterday’s hearing, it is crucial that VA be able to accurately deLeonard.horne on VACREP0180 with DISTILLER

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termine the capabilities of its staff when determining the fitness of 

its infrastructure. I am concerned that VHA does not have the tools 

necessary to make this determination. Even more concerning is the 

idea that VHA is relying on faulty productivity and efficiency data 

while shifting significant resources, including taxpayer dollars, into 

the community and away from VHA facilities. 

It is difficult to believe VHA is confident in its multibillion dollar 

budget request for fiscal year 2018 when it is increasingly evident 

VHA does not have the tools necessary to make decisions using 

proven processes that are based on sound data. In its report, GAO 

made many recommendations similar to those made by Grant 

Thornton in its 2015 assessment of VHA’s productivity. While VA 

has concurred with these recommendations, I am curious as to why 

they were not addressed immediately following the assessment by 

Grant Thornton. 

If the same issues are being raised repeatedly by multiple parties 

almost 3 years apart from each other, I do not think VHA can 

boast of its progress in addressing the issues. I understand that 

some of the recommendations made by Grant Thornton and GAO 

are difficult, even for the private industry, to address, but VA has 

a track record of leading the health care industry, and I will continue to hold VA to that standard, the standard of an industry 

leader. 

I am hopeful VHA will take the issues raised during this hearing 

seriously, and I hope my colleagues and I are able to support you 

as you address these issues in a timely manner. While the adoption 

of a new generation electronic health record system will assist in 

accurately collecting workload data, VA’s capital asset portfolio will 

not wait the 8 or 9 years it will take for VA to set up the new electronic health record system. 

Therefore, this new system cannot be the excuse VHA uses to 

further delay the implementation of both Grant Thornton’s and 

GAO’s recommendations. During today’s hearing, I hope to learn 

more about this issue so that I can support VHA in its efforts to 

develop an accurate and useful system that promotes the productivity and efficiency of VHA’s health care providers. 

Thank you, Mr. Chairman. And I yield back. 

Mr. Wenstrup. Thank you, Ms. Brownley. 

Unfortunately, at this time—you heard the buzzer—they have 

called us over to vote. And I hate when this happens. We are going 

to have to go to vote, and I am going to ask you if you would please 

stay nearby, and we will come back and continue on after the vote 

series that is taking place right now. And I appreciate your patience on that. Thank you. 

[Recess.] 

Mr. WENSTRUP. Welcome back. I am going to take a liberty, because we have a time constraint on this room. Before I introduce 

you, so I can give you a minute or two to prepare, rather than 5 

minutes for your opening statement, if it is possible that we could 

reduce them to 3 minutes, and then we will have adequate time for 

questions. If that is okay, I would like to proceed in that direction. 

So joining us on our first and only panel is C. Sharif Ambrose, 

principal at Grant Thornton LLP, one of the authors of The Independent Assessment; Randall B. Williamson, Healthcare Director 

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from the Government Accountability Office, Dr. Jonathan Perlin, 

former Under Secretary for Health and now the President of Clinical Services and Chief Executive Officer of Hospital Corporation of 

America; and Dr. Carolyn Clancy, Deputy Under Secretary for 

Health for Organizational Excellence, who is accompanied by Dr. 

Murray Altose, the Chief of Staff of the Louis Stokes Cleveland VA 

Medical Center. I want to thank you all for being here. 

And, Mr. Ambrose, you got the short straw, I guess. We would 

like to begin with you and you are now recognized for 3 minutes. 

But having you go first, if you are over a little bit over, I think we 

will be okay with that. So you are now recognized. 

STATEMENT OF C. SHARIF AMBROSE 

Mr. AMBROSE. Thank you. And good afternoon, Chairman 

Wenstrup, Ranking Member Brownley, and Members of the Subcommittee. Thank you for the opportunity to discuss Grant Thornton’s 2015 report on VA provider staffing and productivity. My 

name is Sharif Ambrose. I am a principal at Grant Thornton, 

where I lead our public sector health care practice, and we provide 

consulting services to government clients, including the Department of Veterans Affairs. And it has been our distinct privilege and 

honor to support the U.S. Department of Veterans Affairs and the 

veterans it serves for the past 20 years. 

I am accompanied by my colleague Erik Shannon, who leads our 

commercial health care advisory practice, who also contributed to 

this assessment. 

CAMH served as the program integrator and as primary developer of 11 of the Veterans Choice Act independent assessments. 

CAMH is a federally funded research and development center operated by the MITRE Corporation. 

We conducted our assessment in 2015 of current provider staffing 

levels, caseload, and productivity, and in comparison with health 

care industry benchmarks. 

Among our findings in assessment G is a couple I would like to 

share with the Committee. First, we found that VA doesn’t systematically track fee-based provider productivity and does not capture 

the FTE level information for fee-based provider care providers. We 

also found that staffing levels per patient population were in most 

specialties lower than the industry ratios. The ratios, however, are 

not sufficient to establish whether VHA is staffed to meet demand, 

because of factors that make it difficult to measure clinical workload of VHA and to compare to industry benchmarks. 

Further, we found that the number of patients assigned to VA 

general primary care providers is 12 percent lower than the private 

sector benchmark for patients of a similar acuity. And with respect 

to specialty providers, our analysis shows that VA specialists are 

less productive than their private sector counterparts on two measures: encounters and work relative value units, otherwise known as 

wRVUs. 

We studied root causes, and our team examined many of them 

that drive VHA provider productivity and found several factors 

that limit the ability of providers to optimize productivity. 

First, we found that VA providers have a lower room-to-patient 

ratio than their private sector counterparts. Room-to-provider raLeonard.horne on VACREP0180 with DISTILLER

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tios in the private sector are typically 3 to 1, and we found that 

VA providers typically only have a 1-to-1 ratio, which doesn’t allow 

them to see as many patients as their private sector counterparts. 

Similarly, VA providers have significantly fewer nurses and administrative support staff, which means the providers can’t be as efficient as they otherwise could be. 

We outlined many recommendations in our report. First and foremost is that we recommended that VA evaluate the design and implementation of their staffing models, to which they are sufficient 

to ensure all eligible veterans have access to high-quality and timely care. 

I think I will yield my time, in the sense of time, to the other 

witnesses. Thank you. 

[THE PREPARED STATEMENT OF C. SHARIF AMBROSE APPEARS IN

THE APPENDIX]

Mr. WENSTRUP. Thank you. I appreciate that. 

Mr. Williamson, you are now recognized. 

STATEMENT OF RANDALL B. WILLIAMSON 

Mr. WILLIAMSON. Thank you, Chairman Wenstrup and Ranking 

Member Brownley. VA has developed productivity metrics to measure physician providers’ time and effort to deliver procedures and 

methods to track clinical efficiencies at VAMCs. Using the metrics, 

VHA’s Office of Productivity, Efficiency and Staffing, or OPES, reports data on each VAMC for VAMCs to use in identifying suboptimal clinical productivity and efficiency. 

GAO’s recent study in this area identified limitations with VHA’s 

metrics and methods that limit VHA’s ability to assess whether resources are being used effectively. Regarding productivity, there 

are several needed improvements. First, while OPES reports provider productivity data for 32 different clinical specialties, the data 

only covers VA employed providers. It excludes contracted providers that work at VAMCs and others, such as nurse practitioners 

who are other major contributors to patient care. Also, VA providers are not always accurately coding the intensity of their clinical workload, that is, the amount of effort needed to deliver the 

procedures they perform. Finally, VAMC providers may not always 

be recording their clinical time accurately. 

To its credit, VA has implemented or is developing new initiatives to improve productivity and efficiency data. For example, they 

have intensified training for providers in the field on proper methods for coding, and they are attempting to solve other staffing 

issues as well that relate to labor mapping. 

GAO made recommendations to further improve productivity and 

efficiency data, and VHA has concurred with all of them. 

Perhaps the most significant issue from our study centers around 

VHA’s lack of oversight and monitoring to better ensure that 

VAMCs with suboptimal productivity and efficiency are held accountable for making substantive improvements. Currently, 

VAMCs with suboptimal productivity are required to develop remediation plans and submit them to their respective VISNs for review. However, current VA policy does not require VISNs or CenLeonard.horne on VACREP0180 with DISTILLER

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tral Office to monitor VAMCs’ implementation and resolution of 

these plans. 

Moreover, VAMCs are not required to address or monitor their 

overall efficiency at all. And as a result, they do not develop remediation plans to address inefficiencies identified by OPES data. Our 

review of data shows that some VAMCs perform poorly on these 

metrics year after year, and there appear to be few real incentives 

for VAMCs to improve these metrics. 

In summary, achieving better productivity and efficiency will better ensure that VHA is using resources wisely and maximizing access to health care services for veterans. 

Thank you, Mr. Chairman. 

[THE PREPARED STATEMENT OF RANDALL B. WILLIAMS APPEARS IN

THE APPENDIX]

Mr. WENSTRUP. Thank you very much. 

And, Dr. Perlin, you are now recognized for 5 minutes. 

STATEMENT OF JONATHAN B. PERLIN, M.D., PH.D. 

Dr. PERLIN. Thank you, Mr. Chairman, Ranking Member 

Brownley, and we thank Chairman Roe and Members of the Subcommittee for the opportunity to be here today. 

HCA is the largest private provider of health care services with 

the privilege of about 28 million patient encounters annually. We 

have about 241,000 employees, including 8,000 nurses, exclusive of 

another 37,000 voluntary physicians, and we have the privilege of 

seeing patients at 168 hospitals and 1,200 other sites of care. So, 

roughly speaking, we are similarly sized to VA. 

We also are proud to acknowledge that included in our dedicated 

workforce are many veterans and military spouses, and in the last 

year alone, we hired more than 5,400 military veterans and 1,100 

military spouses, and that led, in 2015, to the Chamber of Commerce Foundation’s Award for Hiring Our Heroes, the Lee Anderson Veteran and Military Spouse Employment Award. 

On that basis, on the basis of my history in VA, I believe that 

I have a unique perspective to offer on this particular topic, having 

served as Under Secretary, Deputy, Chief Quality Officer, and like 

Dr. Shulkin in his current and previous capacity, actually seeing 

patients in VA. 

I note Dr. Shulkin’s 100-day briefing at the White House, where 

he offered a number of observations that he came to from a business and clinical perspective, and I will note three that I believe 

are directly relevant to GAO’s assessment of VA productivity. 

Dr. Shulkin’s first diagnosis of risk concerned access. His comments identified substantial progress overall, including same-day 

access for primary and certain specialty services but also identified 

remaining opportunities for improvement. Obviously, increases in 

provider efficiency are an important means for creating additional 

capacity and access. 

His second diagnosis of risk concerned prompt payment of external providers. This is an area in which legislative relief would be 

helpful. Consolidation of disparate models for obtaining services 

outside of VA and, frankly, comportment with Medicare or private 

insurer reimbursement models would facilitate provider participaLeonard.horne on VACREP0180 with DISTILLER

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tion and increase veteran access to services. The complexity of the 

different VA models imposes statutory inefficiencies on VA’s overall 

management of care both within and outside of VA. 

The third area noted by Dr. Shulkin was quality, and VA is to 

be commended for making their star ratings public. VA is increasingly benchmarking against private sector, and in many instances, 

VA’s performance is as good, if not better, and I note, in particular 

areas, these areas, because they are salient to the comments on 

productivity within GAO. 

GAO notes, as Mr. Williamson said, that the productivity metrics 

are not complete, and the new information system should provide 

a resource for capturing workload. This is a perennial challenge, as 

is the attribution to particular providers, and this is well-demonstrated in the history of attributing performance metrics around 

quality and safety. 

I would note that in our organization, when we think about the 

care of hospitalized patients, rather than trying to capture every 

individual action, we summarize by looking at things like employee 

equivalents per occupied bed. 

GAO also notes that intensity of service may not be quantified. 

That is something that is incentivized more in private sector because it calibrates to a reimbursement. 

So, on the basis of my experience with VA management systems 

of more than a decade ago and my research for this particular 

hearing, I would note that VA’s Central Office has taken steps to 

help VAMCs monitor provider productivity by developing tools to 

oversee performance and efficiency. VA and HCA share a strategic 

and operating advantage in that scale, and within that scale is the 

capacity to look for not only negative but also positive variation. If 

the underpinnings of better performance can be understood, replicated in scale, it becomes the means to elevate the performance 

of the entire system. 

So understanding variation within the system in comparison 

with external performance standards is really why both internal 

and external benchmarking is necessary. Internal benchmarking is 

a tool for learning and management. It can function as an important control system for facilities, for VISNs, and for VACO leadership to manage performance. 

External benchmarking is necessary to understand whether internal performance is superior, consistent with, or inferior to external organizations. External benchmarking is limited by differences 

in data availability and data definitions, but I would note that the 

biggest challenge to external benchmarking is not related to data 

but, rather, certain inherent features of VA and the patients it 

served. 

First, veterans using VA are systematically more complex than 

commercially insured or even mixed commercial-government patients, and so benchmarks need to be calibrated to that increased 

complexity. Second, the VA benefits package is systematically different than either commercial insurance or other government programs like Medicare or Medicaid, and there are many more things 

that VA providers can, should, and really must do to care for veterans appropriately. 

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Indeed, in the capitated system, it is rational to take all necessary actions for preventive services or other interventions that 

reduce the need for future services or subsequent interventions. 

Again, there is this tension between work and recording of work. 

Third, our views were developed in fee-for-service environments 

and really do calibrate recorded work with compensation. In point 

of fact, it is not only about efficiency, but recording quality. In our 

organization, we always look at productivity and compensation together only with quality, which is the nonnegotiable foundation. 

Fourth, in our organization, in our physical plants and, as you 

referenced, the Ranking Member referenced in your statements, 

the VA physical plant doesn’t support multiple exam rooms, and 

this compromises the ability for the most efficient care. 

Finally, I would note that, as you noted as well, that there may 

not be as many supportive staff. And there are times when it may 

be inefficient or inappropriate for VA to produce all of its care internally. And in this respect, I agree with the Secretary’s perspective to use private sector services when geographic access, wait 

times, capacity, demonstrated clinical performance excellence or 

technology are not available in VA. 

Let me close with the comment that looking at quality is obligatory. Quality and safety are always the most efficient. Rework for 

breaches in either is neither efficient nor consistent with the performance excellence the taxpayers deserve and the veterans should 

expect and certainly have earned through their service and sacrifice. 

Thank you. 

[THE PREPARED STATEMENT OF JONATHAN B. PERLIN, M.D., PH.D., 

APPEARS IN THE APPENDIX]

Mr. WENSTRUP. Thank you. Just under 3 minutes. You barely 

made it. 

Dr. Clancy, you are now recognized. 

STATEMENT OF CAROLYN CLANCY, M.D. 

Dr. CLANCY. Thank you. Good afternoon, Chairman Wenstrup, 

Ranking Member Brownley, other Members. I am very happy to be 

here. I am here with Dr. Murray Altose, who is the Chief of Staff 

from the Cleveland VA Medical Center. 

Let me just reiterate that our top priority is improving access to 

care for our veterans, and improving productivity and efficiency is 

a means to that end. 

As the others have noted, we have developed a pretty sophisticated tool that is calculated in industry-based resource: relative 

value units. And this is used widely across our system, and we can 

actually see that by the number of web hits. We have seen an increase of 37 percent in the past year in terms of the number of people actually looking at this. 

Getting to optimal productivity and efficiency is, by definition, a 

team sport, where deployment of providers is continuously evaluated and revised, and there is a very strong collaboration between 

the clinical workforce and the administrative function. 

As others have noted, we implemented clinical productivity 

metrics in 2013 and have developed statistical models to track effiLeonard.horne on VACREP0180 with DISTILLER

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ciency at our medical centers. We have designed reports to provide 

our leaders and facilities and networks with essential tools to understand which clinics are working under, at, or over capacity, and 

we have something called the SPARQ tool that I know you have 

seen, Mr. Chairman, which actually gives our leaders a sense of 

whether clinics are working under, at, or over capacity. 

Since the tool’s introduction, as I noted, we have measured reportable progress, as demonstrated by increase in RVUs. Our system-wide focus on improving access to care, prioritizing urgent clinical needs, and achieving same-day access for veterans with urgent 

primary care or mental health needs has resulted in a 13-percent 

increase in clinical workload, with a concurrent increase in RVUs 

for a clinical employee of 9 percent. 

Specialty practices that are not meeting productivity aren’t required to develop remediation plans. And, in fact, there is a monthly meeting between clinical operational leadership at Central Office 

with the network with those who are reported as outliers, using 

statistical trigger tools. 

We have concurred with the GAO recommendations and are already working to complete them. I want to make note and really 

recognize my colleagues who developed data to assess the clinical 

productivity of advanced practice providers several years ago. In 

most of health care, the work of those providers has been subsumed under the billing done by the clinicians, physicians with 

whom they work. So we will be setting performance standards for 

those providers in the very near future and I believe may become 

actually the reference for other systems, because of expanding full 

practice authority. 

Thanks to the Congress, the group practice managers that we 

have at all of our facilities now overseeing staff and clinic flow I 

think has been one of the most exciting developments in our system. They are charged with specialty practice management and 

have quickly and adroitly begun addressing the myriad issues in 

optimizing clinical practice in realtime. Our best facilities—Cleveland would be one—have established a regular rhythm, with close 

collaboration between the group practice management, the chiefs of 

staff, the service chiefs and so forth, and they are constantly conferring about how to do better. 

And, with that, I think I will simply conclude my remarks. We 

find the GAO’s recommendations helpful. We have made progress 

and will continue to move in that direction. 

[THE PREPARED STATEMENT OF CAROLYN CLANCY, M.D., APPEARS

IN THE APPENDIX]

Mr. WENSTRUP. Well, I thank you all, and I am going to take 

some 5 minutes for questioning. I appreciate you all being here. 

I can tell you a lot of the ideas that I hear coming out of today 

are greatly appreciated, but, to be honest with you, there are a lot 

of ideas that I and other Members of this Committee have been 

talking about and asking to be implemented since I have been 

here, which is 5 years, 2013. 

For example, with metrics, and even as of this week, when I 

asked about being able to measure RVUs, I am told, well, we don’t 

have them for everybody. And today we heard that contractors are 

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excluded. This is not the way to really, in my mind, develop some 

understanding of what is taking place. If we set up metrics, we 

should be able to set up metrics to evaluate the VA health care system in general, each VISN, each hospital, each facility, CBOC, each 

practitioner, for that matter. And it is a matter of simply training 

people to know how to code. 

And what my first question is, are our providers not able to code 

the way that private practitioners do so that we can track RVUs? 

It is a relatively simple system if you know how to bill and how 

to code what you have done. Is that missing from our health care 

system in the VA? 

Dr. CLANCY. Many of our providers are quite good at it. I would 

almost expect certainly that they are less good at it than private 

sector providers, because they don’t have the same direct billing incentive, and we don’t have the same number of expert coders on 

the ground locally. 

So, with that caveat, some are better than others, and we are 

committed to training those who are having more trouble. 

Mr. WENSTRUP. Across the board, contractors and everything? 

Dr. CLANCY. Contractors we have a little more trouble with, because the nature of our contract is that we are not paying for their 

time. We are paying for the services they produce on a fee-for-service basis. So we are not actually hiring someone to work a full day 

in the clinic or half a day. 

Mr. WENSTRUP. Well, then if they are on a fee-for-service basis, 

they know how to code. 

Dr. CLANCY. Yes, exactly. 

Mr. WENSTRUP. So they don’t need the training. 

Dr. CLANCY. Exactly. 

Mr. WENSTRUP. They already got it. 

So you mentioned, Dr. Clancy, that those that are suboptimal, 

they have to present a plan. How can they present a plan if they 

don’t know what they don’t know? It seems to me that a plan 

should be delivered to them. Someone should be assessing their 

clinic and say: Hey, you know what, this 1-to-1 ratio doesn’t work. 

Maybe they don’t know that if that is all they have ever seen. Why 

are they developing the plan when they are already operating a 

system that is doing wrong? I would love to have their advice on 

how they can get it better, but why are we waiting for them to develop a plan? Shouldn’t we be giving them the plan? 

You know, we would do that in our own practice. If one is producing more than the other—and we are always concerned about 

quality; you got to concede that for sure—but, hey, this doctor has 

two medical assistants; you only have one; and they are seeing 

twice as many patients and delivering the same quality. So the 

plan needs to probably come from someone else who has had some 

success. 

Dr. CLANCY. Well, the plans have to be signed off on by their 

service chief. So this is not just asking someone who is doing a bad 

job to tell me how can you do better, okay? 

Secondly, as I think you are aware, many of our facilities—and 

you referenced this in your opening remarks—are very much spaceconstrained. Having three or four rooms to work with feels like, 

you know, something from Star Wars. But most— 

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11 

Mr. WENSTRUP. My question comes into really, or my concern is, 

who is providing the guidance in creating the plan so that they are 

more productive? That I think we have to talk about, because you 

said that they submit their own plan. Well, they are not the experts, obviously, if they are suboptimal. You need someone who 

knows how to be optimal to create the plan, in my opinion. 

Dr. CLANCY. The guidance is two parts: One is technical in terms 

of what do these trigger tool means and what do your metrics actually mean, so that they can understand the delta that we are seeing, particularly if they are not actually all that familiar with it. 

But the real guidance is operational leadership, and I might just 

ask Dr. Altose to chime in on that. 

Dr. ALTOSE. So I would offer that the agenda that is offered to 

the facilities by Central Office I think is reasonable. The priorities 

are set. The resources are distributed. The oversight does take 

place. 

The big issue, in my opinion, is simply operations at the local 

level. And it is complicated because, as has been pointed out in 

much of this testimony, there are many parties who contribute to 

the provision of care, both on an ambulatory basis and in the hospital. 

Mr. WENSTRUP. So this leads to my next question, when you talk 

about incentives. I have not been made aware of incentives for 

quality and productivity that are measured that are there. And you 

said you are working on that. I would like to hear some of your 

ideas, and that is my last question before we move on. 

Dr. ALTOSE. I can also speak to that and point out that, particularly in an ambulatory setting, efficiency and productivity is based 

on a team effort that involves schedulers, clerks, providers, nurses, 

technologists. And each and every one of those parties need to be 

able to contribute, and one aspect lacking is going to seriously compromise efficiency and productivity. 

Reward needs to be offered not to individuals but to teams. This 

is a team effort. It requires an effective team, and rewards need 

to be distributed to the team, not necessarily to any one individual. 

Mr. WENSTRUP. I would agree with that. 

Ms. Brownley, you are now recognized for 5 minutes. 

Ms. BROWNLEY. Thank you, Mr. Chairman. 

I wanted to go back to my opening comments that I made. And 

this question is for Dr. Clancy. And I mentioned in my opening 

comments about, in the current GAO report, they have made many 

recommendations that are similar to the Grant Thornton report 

that took place in 2015. The VA concurred with those recommendations at that time. So I am curious as to why we are now in 2017, 

that was 2015 why haven’t we met those recommendations of 

which you said at that time, I believe, that you concurred and 

would work towards? And now you are saying you are going to 

work towards the GAO recommendations as well. So is it a lack of 

budget, tools, what? 

Dr. CLANCY. I think one of the biggest critical gaps for us has 

been getting the right people into key leadership positions. I mean, 

at our best facilities, this culture and strong sense of it is a team 

sport starts from the top. And it was one of Dr. Shulkin’s, when 

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12 

he was Under Secretary, top priorities was to make sure that we 

filled critical gaps in leadership across our system. 

Some of those are only recently filled, but we are in so much better shape since he started at VHA. And with our system, that took 

time to get the right people into their seats. Meanwhile, at every 

level, we are seeing much more attention to the technical tools. 

So the two game-changers, I believe, are the full practice authority for advanced practice nurses. And, also, we have already got the 

tools to know how much they are contributing in terms of RVUs. 

And the second is the group practice managers. Now, getting that 

practice up and all those slots filled I would say has taken over a 

year, but we are now at full or very close to 100 percent capacity 

there. They have been trained in what is essentially a new role in 

our system and one that I think is very, very important. 

That is why I was expressing our appreciation to the Congress 

for insisting on this, because trying to figure out exactly what this 

person was, how they would fit in the existing system did take 

some time, and it took some training for them to understand how 

they would be doing their jobs. But I think that we are beginning 

to see the benefits of that now. 

Ms. BROWNLEY. Thank you. And I also wanted to follow up with 

you on—I think in your testimony back in May of 2016, the VHA’s 

Health Information Management Program Office developed and implemented training for providers to improve coding accuracy. So 

have all the providers now received this training? 

Dr. CLANCY. They have certainly all been offered. I would take 

it for the record to tell you exactly what proportion. As you know, 

in our system, we have some regular turnover among providers, 

but we are committed to reaching those, A, who haven’t been 

trained or have somehow missed the opportunity and, B, are not 

doing so well. That is going to be our first priority focus rather 

than a blanket across the board for people who are already doing 

a good job. 

Ms. BROWNLEY. So, just so I understand, so the people who have 

been on board and have not—you talked about the churn and I get 

that, that piece of it. But are you talking about just the churn not 

having been trained or still others in the organization that have 

not been trained? 

Dr. CLANCY. Well, in some of our organizations, we have people 

who are effectively working part-time, because they have got split 

appointments with academic affiliates. They may have teaching responsibilities and so forth, which is also another factor in considering how our productivity stacks up against the private sector. Do 

they have those same missions or not? 

I wouldn’t be shocked to know that some of them may have not 

taken full advantage of the opportunity to be trained, and we will 

be making sure that everyone gets it. 

Ms. BROWNLEY. And then, once a provider has been trained, then 

how are you holding them accountable? 

Dr. CLANCY. Again, this is a regular review, and we are reviewing centrally, in terms of who are the outliers. Right now, for example, our best estimate—or at the end of 2016—was that 14 percent 

of our specialty practices are under capacity, working under capacity in terms of productivity. 

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13 

And then there is a question of diagnosis. Is it that the physicians are not doing their best work, or is it, as in one place I visited, that there are no schedulers—there are almost no schedulers 

to schedule patients for them to see, which obviously would be a 

problem—and so forth? So that is how we are putting this all together. 

Ms. BROWNLEY. Thank you. 

And may I have another minute? 

For HCA, in your testimony, you state that accurately capturing 

the workload of providers who are managing the care of hospitalized patients is difficult, even in the private sector. In order to 

mitigate the administrative burden of providers, you recommend 

that workload be captured as a byproduct of work. 

And I guess my question is, is there a system in the private sector that the VA could look to or purchase off the shelf that would 

achieve the sort of accurate capture of this information? 

Dr. PERLIN. Thanks, Congresswoman. 

That is a terrific question. The systems, the electronic health 

records used in the private sector are really optimized for the coding efficiency. In point of fact, it takes much of the burden for coding off the provider and allows, frankly, less expensive, more efficient people to code behind the scenes so that the provider is taking care of patients and the coders are coding. So I think there is 

a workflow issue that could be used in the near term. 

In the longer term, recognizing the Chairman’s comment that he 

didn’t want to wait until the full re-platforming, as VA does replatform, I suspect that that system will have many of those tracers embedded so that workflow can be and captured as a byproduct 

of work rather than counterproductive additional work. 

Ms. BROWNLEY. Thank you. 

I yield back. 

Mr. WENSTRUP. Dr. Dunn, you are now recognized for 5 minutes. 

Mr. DUNN. Thank you, Mr. Chairman. 

I want to note that this particular topic, productivity, efficiency, 

quality, these determine value, and this very subject is going to occupy the attention of this Committee and I think the larger Committee, as it has for years. It is going to be a real focus going forward, and we are going to try to finally find the light on this subject, I hope. And I am grateful, by the way, to have such an august 

group of consultants that we can ask for input on this difficult subject. 

Mr. Ambrose, your findings, between the productivity of private 

practitioners and the VHA were intriguing. They are able to measure productivity with the cost of deliverables, and the cost of delivering, like the cost of delivering an office visit, surgery, drugs and 

so on. You agree that this is a rational and effective way to measure productivity? 

Mr. AMBROSE. Well, thank you for the question, Congressman. If 

I understood your question correctly, cost is certainly a component, 

both at the episodic level as well as the patient level that should 

be looked at. And I believe VA has the ability to measure cost, just 

like other provider systems do. We did not in our study— 

Mr. DUNN. I noticed you didn’t, but I was hoping that that was 

the next thing. I read your study. 

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14 

Mr. AMBROSE. Yes. So we did not have a discussion nor did we 

analyze that data. 

Mr. DUNN. Do you think there is a way we can get to that data, 

quickly, easily? 

Mr. AMBROSE. Well, I believe VA has a cost accounting system 

that assigns costs to encounters for patients and by provider. So I 

do believe that there is a way to analyze that data. 

Mr. DUNN. I was thinking of you, in your role as an auditor, 

would you just take that data or would you—you would be auditing 

that, right? 

Mr. AMBROSE. Well, I think the way we normally approach 

things is we look at data, but then we also look at it in the context 

of— 

Mr. DUNN. How it is gathered. 

Mr. AMBROSE [continued]. —the environment. We talk to the 

physicians, the management, to understand what the data represents, how it is collected, to make sure that we are able— 

Mr. DUNN. Because we are so short on time, I am going to cut 

you off. But I want to say that the cost of deliverables is a number 

that is important, I think. It is important to me, and I think it is 

important to the VA as well. 

Dr. PERLIN, you highlighted that some of the biggest challenges 

the VA faces are with external benchmarking, and I thank you also 

for your testimony. And I would be remiss if I didn’t slip a kudos 

in for you for my partner—Mr. Poliquin, the Member from Maine 

who usually sits on my right side. 

The comment on prompt payment of external providers is of concern and would be something where legislative relief would be 

helpful. Do you have a quick answer on legislative relief that you 

would recommend for that? 

Dr. PERLIN. Thank you very much for that question. Right now, 

the VA is grappling with eight, as I understand it, different payment mechanisms for care outside of the VA. As well, it is really 

administered as a benefits program, not a reimbursement program, 

as most of the transactions are, whether they are with Medicaid 

and other governmental payers or whether they are with commercial insurance. 

So giving VA the tools to actually work more in that domain 

would be inherently more efficient and would allow that interaction 

to be much more seamless, and I believe as a derivative of that 

would— 

Mr. DUNN. I would love to hear your comments offline perhaps 

separately about what we can do to really relieve that problem, because we are all anxious to relieve that problem, along with many 

others. 

You also said that there are times when it is inefficient or inappropriate for the VA to internally produce all the care veterans 

need, whether for geographic, wait times, capacity, or demonstrated clinical performance excellence or technology that just 

wasn’t available in the local VA. Does this sound like the Choice 

Program to you? 

Dr. PERLIN. I think those are elements of the Choice Program, 

but really, those are the Secretary’s words that relate to the reasons to get care outside. No health system can be all things to all 

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15 

people perfectly in all places. VA is remarkable in terms of caring 

for incredibly complex vulnerable patients. It provides glue and 

continuity, but certain services clearly would be more efficient in 

other environments. 

Mr. DUNN. Thank you. As it relates to the external 

benchmarking—I love that part of your testimony—you said it is 

obligatory to look at productivity and quality simultaneously. And 

I would like that also, you know, the external benchmarking to be 

kind of marched over to that area as well, because I have worked 

in VAs and HCAs, and I see differences. 

Mr. Chairman, I yield back. Thank you. 

Mr. WENSTRUP. Mr. Takano, you are now recognized. 

Mr. TAKANO. Thank you, Mr. Chairman. 

I have a question for the GAO. The GAO’s report highlighted the 

VA Central Office that the VA Central Office does not require the 

VA Medical Centers to monitor efficiency models or to address inefficiencies identified by them. It only encourages them to do so. 

Mr. Williamson, can you talk a bit about the challenges that this 

creates? 

Dr. PERLIN. Sure. Oversight and accountability seem to be endemic in VA for a lot of areas. This is certainly one of them. We 

have OPES reports, data on efficiency, for example, and VAMCs 

basically, at least the ones we visited are basically ignoring that, 

because there is no incentive for them. Nobody is held accountable 

to provide any remediation plans. It is data that is out there, and 

those facilities that take it seriously probably do something. But, 

again, there is a raft of data that OPES puts out there, and a lot 

of the VAMCs don’t have the capability, the technical capability, or 

the capacity to do that. 

But incentivizing it—a good example is the SAIL data, which you 

are familiar with. There is a star rating system. There are five 

things that are measured, in terms of quality, access, patient satisfaction, productivity and efficiency. Productivity and efficiency are 

excluded from that star rating, so they are not part of that data. 

The data is there, and it is recorded, but it is not—and that star 

rating system is, in part, used for performance pay for the leadership of each VAMC. So it is a serious problem. 

Mr. TAKANO. The VA does have—the Central Office does have 

the authority—well, that is my question. It has the authority to go 

further than encouraging them? Does it have the authority to mandate it or to direct them to do that? 

Dr. PERLIN. They have that authority. I would hope that Deputy 

Under Secretary for Health for Operations has that authority. And 

I think that, in Dr. Clancy’s testimony, that she indicated they are 

going to take more of a role in that. But I would like to see that. 

Mr. TAKANO. The GAO also observed that the Central Office does 

not have a systemic process in place to monitor these efforts, that 

the medical centers and the VISNs are not required to submit remediation plans to the Central Office, nor does the policy state that 

VISNs or the Central Office must monitor the implementation of 

the remediation plans. 

In your opinion, without direct oversight from the VA Central Office, are best practices being identified, actually? 

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16 

Dr. PERLIN. I don’t think so. I think it could be better because, 

without some kind of clearinghouse beyond the VISN level that allows you to share best practices, it is very difficult. 

And, you know, VA talks about weekly meetings and monthly 

meetings where they talk about these things, but a lot of times 

those may not be well attended. There is no assurance that those 

best practices are out there. It probably needs to be a little more 

formalized, in my opinion. 

Mr. TAKANO. All right. Well, I am kind of interested to see this 

amazing sort of relationship between the Central Office and the 

medical centers. I am kind of surprised myself to learn this. 

But I yield back. Mr. Chairman. 

Mr. WENSTRUP. Mr. Bilirakis, you are now recognized. 

Mr. BILIRAKIS. Thank you, Mr. Chairman. I appreciate it very 

much. 

And thank you to the panel for your testimony as well. 

A lot of my questions were already answered, but, Dr. Clancy, 

you testified that the VA is in the midst of developing standards 

for advanced practice providers. When can you expect those standards to be released? 

Dr. CLANCY. I believe we have committed to it later this year. I 

want to just emphasize that this is an area where we don’t have 

external benchmarks to refer to very easily because historically the 

work of physician assistants, advanced practice nurses, and so 

forth has been subsumed under the billing by physician. So we 

can’t easily turn to another large system and say, what are the 

standards? So, to some extent, we will be, I think, as the Ranking 

Member noted earlier, in the lead on this particular area and may 

end up being a reference for others. 

Mr. BILIRAKIS. Can you please follow up with that with me? I 

would appreciate that. 

Let me ask a question, Dr. Perlin, with regard to medical scribes. 

You are familiar, obviously, with medical scribes. Are you using 

medical scribes within the HCA system? 

Dr. PERLIN. We have scribes in certain environments. It is not 

consistent, but it is part of certain practices. 

Mr. BILIRAKIS. Would you recommend that they be used within 

the VA? Now, I know to a certain extent—I want to ask this question to the VA too. Are we using medical scribes within the VA, 

and to what extent? 

Dr. CLANCY. I know we are using them in some facilities. I would 

have to get back to you with a more robust answer in terms of— 

Mr. BILIRAKIS. Why wouldn’t be they be widespread in the system? I know there are several advantages to that. Are there any 

drawbacks? Why don’t we have them in place within the entire system? And I want you to elaborate also, Dr. Perlin, on what the use, 

how beneficial they are. 

Dr. PERLIN. Let me maybe start by providing context. They sometimes relieve the physician or other provider of the burden of entering the information. It is an individual choice. There are providers 

who are very proficient with electronic health records, myself included, for whom it actually it would be an inefficiency in terms of 

working through someone else. 

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17 

The other inefficiency that they can offer is that one of the best 

parts of electronic records is that they can provide decision support, 

and that decision support is kind of hard to intermediate by someone who tells you: Oh, we got this warning for this. 

So there may be circumstances where efficiency can be increased, 

certainly for some surgical specialties where someone can serve 

that function as well. There may be situations in which advanced 

practitioners who accompany those surgeons or other providers 

may add that efficiency. 

But I think the broader question, the one you are getting at that 

I think is so important, is, how do you just increase the efficiency 

of both the individual provider as well as the overall team? 

Mr. BILIRAKIS. Right. Dr. Clancy, again, if a physician within the 

VA requests a scribe, are they readily available, and why not, if 

they are not available? 

Dr. CLANCY. So I would agree with Dr. Perlin that scribes are 

one very specific and very helpful tool for increasing efficiency. In 

other cases, there is a whole lot of else that we could be doing in 

a practice. 

In one of our networks, the network that includes most of Pennsylvania, they have recently begun using scribes and have seen 

dramatic increases in efficiency and are actually going to be bringing their lessons learned back to share with others. 

In one recent thing that we did—and I have to look at the other 

Chairman for a moment—recently was to actually go through our 

view alerts and figure out how could we get rid of some of those 

that are actually a huge distraction and preventing physicians from 

seeing the most important messages. And as a result of this system-wide effort, we were actually able to give back about an hour 

and a half a week to primary care physicians, which, again, is another increase in efficiency and, frankly, decrease in sort of irritation, if you will. 

So I would be happy to make sure that we get you better information on how the scribes are used. I think, as Dr. Perlin said, it 

is often an individual choice and may be competing with resources 

for other types of support for the team and the practice. 

Do you use them at Cleveland? 

Dr. ALTOSE. No. Very, very little. There is very little use in 

Cleveland of scribes. The providers will record it on the electronic 

medical record. And we extensively use voice recognition software 

so that reports can be dictated by the providers. 

Mr. BILIRAKIS. Thank you very much. 

I yield back. Mr. Chairman. 

Mr. WENSTRUP. I am going to indulge Chairman Roe. If we may, 

we will have one more round of questions—time with Mr. Correa 

will be recognized. But I know this room is going to be occupied 

shortly. 

Mr. ROE. It will be quick. 

Mr. WENSTRUP. It will be quick. Mr. Correa, you are now recognized. 

Mr. CORREA. Dr. Roe, if you would like to go, go ahead, sir. You 

said ‘‘quick’’? 

Mr. ROE. You go ahead. 

Mr. CORREA. Please. 

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Mr. ROE. I think Dr. Wenstrup and others, and Dr. Dunn, those 

who have practiced medicine for a long time have seen a lot of the 

joy leave medicine, and most it is checking boxes. I call that 

polyboxia, where you just check all these boxes. And if you check 

the right boxes, you are a good doctor; and if you don’t, you are a 

bad doctor, no matter how your patient actually ends up. It is a 

great source of frustration, both inside the VA—and you mentioned, Dr. Clancy, the number of prompts that my friends who are 

at the VA, sometimes 200 a day. That is so distracting; you can’t 

possibly practice if you are doing that. 

I think that we are going to see the use of medical scribes more 

and more, and certainly, in some places, they can be very efficient. 

I talked to a group of ophthalmologists in a community not too far 

from mine where there were five of them. They all use one or two 

scribes. Five doctors see 55,000 patients a year. 

And I know that when we put an electronic health record in our 

office, it slowed me down. I saw less patients and extended my day. 

That was really wonderful. And I couldn’t tell much benefit. I think 

it has gotten better. I think the EHRs have gotten better. 

But certainly, at the VA, and I have heard Dr. Wenstrup say this 

many, many times about, if we only saw as few patients as most 

primary care doctors do at the VA, we could just lock the door and 

leave, because you couldn’t pay your bills. And in private practice, 

that is the case. I believe I am right. And that is what he has tried 

to get out about how much does it cost you to actually see a patient 

at the VA? And, quite frankly, it is hard for anybody to quantify 

that, but we could pretty much tell you in our practice, because at 

the end of the year, if we paid our bills, how much I got paid. That 

is not the case at the VA. 

So we have a bill and Dr. Wenstrup and I have this bill we are 

going to mark up on Monday I think it is that is going to get a pilot 

program for scribes. I will tell you, in all of the studies I have 

read—and I have read several of them—in urology, general surgery, and others, where they have to see a lot of patients in a day, 

it has made their practice more enjoyable, and it has made it more 

efficient. And they have actually done a better job of coding than 

the doctors do. I did a lousy job of it. I know I did. I didn’t like 

it, and so I didn’t do a very good job of it. 

I think the other thing that you will be able to do is, with this, 

with better data going in, I think you are going to be able to better 

manage populations and get better patient outcomes. I really think 

you will be able to do that. 

And is the VA willing to go ahead—I guess I will ask Dr. Clancy 

this—if we pass this bill and it gets through the Senate, implement 

a scribe program? And hopefully in the next year or so, we will 

have an answer, because it shouldn’t be hard to get these people 

hired. 

Dr. CLANCY. Absolutely. And, you know, frankly, building on 

what we have already started to see in Pennsylvania, I think it 

would be terrific. 

Mr. ROE. I will yield back. 

Mr. WENSTRUP. Mr. Correa, you are now recognized. 

Mr. CORREA. Thank you, Mr. Chairman. 

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A general question to the panel. As we rush to transform the VA 

better, leaner, more responsive, we talk about terms such as productivity, efficiency, quality, looking at off-the-shelf systems to try 

to integrate them. A question to each and every one of you is: System integration, information systems, as we look at the Kaisers of 

the world and we look at the private sector—a big challenge in the 

private sector, of course, is those information systems are not integrated so the information here does not flow to here, so on and so 

forth. What attention, what are you doing to assure that the VA 

itself, as you transform it to something better, whatever that may 

mean, is fully integrated to be responsive to the needs of the patient? 

Dr. CLANCY. So I think you have—Congressman, it is a great 

question and you have put your finger on two very, very important 

issues. 

A third game-changer I believe for access and for being responsive to patients is telehealth. Now, we use this a lot in very different ways. We use it for everything from virtual visits to good 

old-fashioned telephone visits to video encounters with specialists 

and so forth. And ultimately, I think that we will be doing this in 

patients’ homes. And we do that in some States right now. How 

much nicer for a patient with PTSD to get his counseling and therapy from his own home rather than driving 3, 3-1/2 hours to the 

nearest medical center and so forth. And that has been very, very 

successful. 

Historically, at VA, it has been really wonderful but sort of separate from all of our other systems. And increasingly in the past 

year, year and a half, we have been integrating that with all of our 

efforts to make sure that we address our top priority of access to 

care. 

So I think that is going to be a game-changer, because in addition to making it much better and much more responsive to what 

veterans need and want—I mean, navigating our system or any 

health system is not a joy unto itself—it is also a terrific platform 

to extend the expertise of specialists, who tend to be at some of our 

larger, more complex medical centers, out to the outlying community-based outpatient clinics and so forth. 

Mr. CORREA. If I may follow up, what are you doing to make sure 

that, as you come out with this productivity tool that will multiply 

your ability to reach out at these, you know, people that live out 

in areas that are difficult for them to come to the VA, what are we 

doing to make sure that they understand that this is something 

that is good and not just a cost-cutting measure and, therefore, 

maybe they may think, patients may think that you are sacrificing 

efficiency for cost savings? Are we following with some surveys, 

with some actual studies to make sure that, in the process to deliver these services, quality is not being sacrificed? 

Dr. CLANCY. Yes. We are actually surveying veterans to see how 

well this works for them. In fact, a big fundamental linchpin of our 

same-day access for urgent mental health or primary care needs 

has been that that may be a face-to-face visit, it may be a virtual 

visit, or a phone call, or some other way that we are helping you 

resolve your problem today. But the point is we are not going to 

be forcing this on people who don’t want it. But, by and large, I 

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20 

would say industry experience has been that people for the most 

part really like it a great deal. So you see the Kaisers of the world 

doing more and more of it. 

Mr. CORREA. Thank you very much. 

I yield the remainder of my time. 

Mr. WENSTRUP. As you can tell by the crowd outside, our rent 

is due and the new tenants are ready to move in. So we are going 

to have to conclude, and I would encourage anyone, if they have 

any further questions, to please submit them for the record. 

So, at this time, the panel is now excused. 

And I ask unanimous consent that all Members have 5 legislative days to revise and extend remarks and include extraneous material. 

Without objection, so ordered. 

And the hearing is now adjourned, and I thank you all for being 

with us today. 

[Whereupon, at 4:28 p.m., the Subcommittee was adjourned.] 

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1This law was later amended by the Department of Veterans Affairs (VA) Expiring Authorities Act of 2014 (Public Law 113–175). 

A P P E N D I X 

Prepared Statement of C. Sharif Ambrose 

Good afternoon Chairman Wenstrup, Ranking Member Brownley, and members of 

the Subcommittee. Thank you for the opportunity to discuss Grant Thornton’s 2015 

findings and analyses that focused on VA Provider Staffing and Productivity. My 

name is Sharif Ambrose and I am a Principal at Grant Thornton LLP where I lead 

our Public Sector Healthcare Practice that provides contracted consulting services 

to government clients, including the U.S. Department of Veterans Affairs. I am accompanied by Erik Shannon, a fellow Partner at Grant Thornton who leads our 

commercial healthcare advisory practice and who also contributed to the 2015 Independent Assessment. 

Grant Thornton is one of the largest professional services firms in the world and 

we provide our clients across all major industries with advice on strategic, operational, financial, and technology issues to help them achieve their missions. Our 

health care practioners serve commercial and government health providers, health 

plans, and life sciences clients to create, protect, and transform value across their 

organization. It has been our distinct privilege and honor to support the U.S. Department of Veterans Affairs (VA) and the Veterans it serves for the past 20 years. 

Grant Thornton’s involvement in this assessment began after Congress enacted 

and President Obama signed into law the Veterans Access, Choice, and Accountability Act of 2014 (Public Law 113–146) (‘‘Veterans Choice Act’’). 1 This law was intended to improve access to timely, high-quality health care for Veterans. Under 

Title II - ‘‘Health Care Administrative Matters,’’ Section 201 called for an Independent Assessment of 12 areas of VA’s health care delivery systems and management processes. 

VA engaged the Centers for Medicare & Medicaid Services (CMS) Alliance to Modernize Healthcare (CAMH) to serve as the program integrator and as primary developer of 11 of the Veterans Choice Act independent assessments. CAMH is a federally funded research and development center (FFRDC) operated by The MITRE Corporation, a not-for-profit company chartered to work in the public interest. CAMH 

subcontracted with 3 firms with technical and industry expertise - Grant Thornton, 

McKinsey & Company, and the RAND Corporation - to conduct 10 independent assessments as specified in Section 201, with CAMH conducting the 11th assessment. 

Part G of Section 201 required an independent assessment of ‘‘the staffing level at 

each medical facility of the Department and the productivity of each health care provider at such medical facility, compared with health care industry performance 

metrics.’’ 

To address this requirement under Part G, Grant Thornton conducted an assessment during the winter and spring of 2015 of current provider staffing levels, caseload, and productivity, in comparison to health care industry benchmarks. This included an in-depth assessment of nurse staff resource allocation, decision-making, 

and processes which impact provider productivity and efficiency. 

• Our team interviewed VHA policy leaders and subject matter experts from the 

major specialties as well as the leaders of the program offices responsible for 

reporting VHA staffing levels and provider productivity. 

• We obtained staffing, workload, and time allocation data of VHA providers from 

VHA for fiscal year 2014. 

• In coordination with other Choice Act independent assessment teams, we visited 24 VA Medical Centers and community-based outpatient clinics (CBOCs). 

The purpose of the site visits was to interview local facility leaders and providers to understand the local management practices, staffing, caseload and 

productivity levels across VA. 

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22 

Our report, along with the other independent assessments, were provided to the 

Secretary for Veterans Affairs, the House Committee on Veterans’ Affairs, the Senate Committee on Veterans’ Affairs, and the Commission on Care in September 

2015. 

Provider Staffing Findings 

Grant Thornton’s assessment found VA medical centers face issues with provider 

vacancies, lengthy hiring processes, and competitive compensation, each of which 

can contribute to provider shortages. Assessment G noted three primary findings. 

Finding 1: VHA specialties with the highest provider full-time equivalent (FTE) 

levels include medicine specialties, mental health, and primary care, consistent with 

VHA’s care model and the needs of the Veteran population. 

Finding 2: VHA does not systematically track fee-based provider productivity, and 

does not capture FTE level information for fee-based care providers. 

Finding 3: VHA physician staffing levels per patient population are, in most specialties, lower than industry ratios. These ratios, however, are not sufficient to establish whether VHA is staffed to meet demand because of factors that make it difficult to measure clinical workload at VHA and to compare VHA performance to industry benchmarks. For instance, VHA uses Advanced Practice Providers (APPs) extensively but the FTE for these types of providers are not included in VA’s data. 

Provider Productivity Findings 

In comparing VHA providers to providers in the private sector, our assessment 

used several common health care industry productivity measures: 

• encounters (count of direct provider-patient interactions in which the provider 

diagnoses, evaluates, or treats the patient’s condition), 

• work relative value units (wRVUs-a measure of a provider’s output which takes 

into account the relative amount of time, skill, and intensity required to complete a given procedure), and 

• primary care panel size (the number of unique patients for whom a care team 

is responsible). 

Our team considered VHA’s care model, benchmarked providers accordingly, and 

considered the barriers VHA faces in delivering care at a rate of productivity that 

matches health care systems in the private sector. In comparing the productivity of 

VHA providers to industry benchmarks, our analysis supports two key findings: 

1)The number of patients assigned to VHA general primary care providers is 12 

percent lower than the private sector benchmark for patients of a similar acuity. 

2)With respect to specialty providers, our analysis shows that VHA specialists are 

less productive than their private sector counterparts on two industry measures - 

encounters and work relative value units (wRVUs). Many specialties fall in the 50th 

percentile of private sector providers; others are as low as the 25th percentile. However, when encounters (visits) are used as a measure, the gap shrinks and VHA specialty care compares more favorably to the private sector. In a system as large and 

varied as VHA, we did find variation in the relative productivity of providers. For 

instance, specialty care providers at the most complex facilities were found to be 

more productive than their peers, and the most productive VHA providers (those at 

the 75th percentile of VHA providers) are often more productive than the private 

sector. Mental health provider productivity at VHA was calculated to be in the 

100th and 72nd percentiles as measured by both wRVUs and encounters, compared 

to industry benchmarks. 

Root Causes 

Our team examined the various drivers of VHA provider productivity, and found 

there are several factors that limit the ability of providers to optimize productivity. 

For example: 

We found VHA providers have a lower room-to-patient ratio than the private sector. Private sector room-to-provider ratios are typically 3-to-1 and we found VHA 

providers typically only have a 1-to-1 ratio, which does not allow them to see as 

many patients as their private sector counterparts. Similarly, VHA providers have 

significantly fewer nurses and administrative support staff, which means the providers cannot be as efficient as they otherwise could be. Insufficient clinical and administrative support staff results in providers and clinical support staff not working 

to the top of their licensure. 

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23 

Another challenge is VHA does not effectively manage nurse absences (using 

nurse float pools), resulting in unplanned staff shortages and fewer patients who 

can be treated. 

While there has been widespread implementation of the Patient Aligned Care 

Team (PACT) model in primary care clinics and the National Nurse Staffing Methodology in many areas of inpatient care, there are no current VHA standards for 

staffing levels and/or mix in specialty clinics, with the exception of eye clinics. 

Based upon our team’s observations and the findings of Assessment F (Clinical 

Workflow), we have concerns providers may not be properly documenting all of their 

workload, which may explain some of the difference in productivity across all facilities. During site visits and interviews with VHA Central Office leaders, we consistently heard concerns that providers do not fully document and accurately code all 

of their clinical workload. 

Grant Thornton’s Recommendations 

In formulating our recommendations in 2015, our team considered the findings 

and recommendations of the other Veterans Choice Act Assessments, prior reports 

by the VA Office of the Inspector General (OIG), the Government Accountability Office (GAO) and other government bodies available at the time. 

In our report we offered five overarching recommendations to VHA along with the 

supporting evidence for each recommendation, relevant promising or best practices, 

and potential near-term actions or next steps. We also provide a discussion of crosscutting implementation considerations that may be used to develop, enhance, or 

speed implementation of the recommendations. By implementing these recommendations, along with the recommendations of the other Veterans Choice Act 

Assessments, VHA can - with the support of Congress - evolve into a consistently 

high performing health system, enabling access to high quality care in an efficient 

and cost effective manner. 

Recommendation 1: VHA should improve staffing models and performance 

measurement. 

VA should evaluate the design and implementation of current VHA staffing models to determine the extent to which they are sufficient to meet the goals of VHA’s 

population health focused model and ensure all eligible Veterans have access to high 

quality, timely care. VHA should conduct a program review of the implementation 

of the PACT staffing model in primary care to identify the causes of the productivity 

shortfalls and the impacts of these performance gaps on access to quality care. VHA 

should develop and implement staffing models for outpatient specialty care services 

and improve existing performance measurement systems to realize the benefits of 

specialty care staffing models. VHA should refine and implement the National 

Nurse Staffing Methodology across inpatient services and improve the performance 

measurement system to realize the benefits of the methodology. 

To improve staffing and productivity measurement and better determine the capacity of VHA specialty clinics, Grant Thornton’s assessment recommended the 

VHA gather data and assess the productivity of fee-based providers, as well as conduct a work measurement study (or verify existing workload data) to determine the 

volume and distribution of workload each year to better match staffing requirements 

to demand. 

Recommendation #2: VA Medical Centers should create the role of clinic 

manager and drive more coordination and integration among providers 

and support staff. 

VA has an opportunity to increase the level of teamwork and accountability 

among all outpatient clinic staff, especially in specialty care services. This might be 

achieved by creating multidisciplinary management teams for specialty clinics that 

include a physician leader, nurse leader, and business administrator. Alternatively, 

specialty clinics might establish a single or dual reporting line and operating a 

model for providers and their clinical and non-clinical support staff, so all of the 

members of the specialty clinic team have more accountability to each other and the 

Service Chief of the specialty. 

Recommendation #3: VA Medical Centers should implement strategies for 

improving management of daily staff variances, and include a replacement factor for all specialties, including PACT. 

With respect to managing staff absences, VA can improve the management of 

daily staffing variances by implementing several strategies that include intermittent 

float pools of support staff and the inclusion of a replacement factor across all staffing methodologies/models, to include PACT. 

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1GAO, VA Health Care: Improvements Needed in Data and Monitoring of Clinical Productivity and Efficiency, GAO 17 480 (Washington, D.C.: May 24, 2017). 2 In 2012, VA’s Office of Inspector General (OIG) recommended that the department establish 

clinical productivity metrics for providers at VA’s medical centers. VA OIG, Veterans Health Administration: Audit of Physician Staffing Levels for Specialty Care Services. 11–01827–36. 

(Washington, D.C.: Dec. 27, 2012). Clinical productivity refers to the workload performed by 

VA’s clinical providers over a given time period. 

Recommendation #4: VA Medical Centers should implement local best practices that mitigate space shortages within specialty clinics. 

VA medical facilities should further study opportunities to mitigate space shortages within specialty clinics. These include strategies such as: standardized schedule templates, expanded clinic hours, increased use of non-face-to-face encounters 

for follow-up consults by specialty care, and system redesign initiatives to improve 

patient flow within clinics. 

Recommendation #5: VHA should improve the accuracy of workload capture. 

VHA should conduct an audit of health record documentation and current procedural terminology (CPTr) coding accuracy and reliability to validate physician productivity measurement and that if the results support it, evaluate the ability of commercially available computer assisted coding (CAC) applications to assist providers 

with coding. The creation of the role of clinic manager for Specialty Care clinics 

should also be used to improve clinic management and coding practices. 

Closing 

In a health system comprised of more than 150 hospitals and nearly 1,400 community-based outpatient clinics - among other care settings - determining the staffing levels, caseload, and productivity required of VA providers to meet the needs of 

more than 9 million enrolled Veterans is a complex task. Adequate provider staffing 

levels and a health care system that enables its clinicians to be productive in delivering VHA’s population-health focused model of care are essential to meeting the 

goals of timely, high quality care for our nation’s Veterans. I applaud this committee, the Department and the often overlooked dedication from the VA health care 

providers and support staff who have chosen to serve our nations’ Veterans. Grant 

Thornton is grateful for the opportunity to address this committee and to offer our 

analysis of the challenges facing VA. 

f 

Prepared Statement of of Randall B. Williamson 

VA HEALTH CARE 

Improvements Needed in Data and Monitoring of Clinical Productivity and 

Efficiency 

Chairman Wenstrup, Ranking Member Brownley, and Members of the Subcommittee: 

I am pleased to be here today to discuss our report on clinical productivity and 

efficiency at the Department of Veterans Affairs (VA). 1 As you know, VA’s total 

budgetary resources for its Veterans Health Administration (VHA) have increased 

substantially over the last decade, rising from $37.8 billion in fiscal year 2006 to 

$91.2 billion in fiscal year 2016. As VA’s funding levels increase, it is increasingly 

important that the department spend these funds wisely and ensure that VA attains 

high levels of productivity among its clinical services and operational efficiency to 

maximize veterans’ access to care and minimize costs. 

Beginning in fiscal year 2013, VA began implementing clinical productivity 

metrics to measure physician providers’ time and effort to deliver various procedures in 32 clinical specialties. 2 In addition, VA developed 12 statistical models to 

measure clinical efficiency at VA’s medical centers (VAMC). Under the models, VA 

calculates each VAMC’s utilization and expenditures for different high volume or 

high expenditure components of health care delivery, such as emergency department 

and urgent care, and determines the extent to which utilization and expenditures 

differ from expected levels. The Office of Productivity, Efficiency, and Staffing 

(OPES), within VA Central Office, is responsible for calculating both the provider 

productivity metrics and the VAMC efficiency models. 

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3The six VAMCs we selected are located in Atlanta, Georgia; Baltimore, Maryland; Harlingen, 

Texas; Las Vegas, Nevada; Saginaw, Michigan; and Salem, Virginia. 4 VA Central Office is responsible for managing and overseeing the VA health care system and 

delegates certain responsibilities to its VISNs. 5GAO, Standards for Internal Control in the Federal Government, GAO/AIMD 00 21.3.1 

(Washington, D.C.: November 1999) and Standards for Internal Control in the Federal Government, GAO 14 704G (Washington, D.C.: September 2014). Internal control is a process effected 

by an entity’s oversight body, management, and other personnel that provides reasonable assurance that the objectives of an entity will be achieved. 

My testimony today summarizes the findings from our recent report analyzing 

VA’s clinical productivity metrics and efficiency models. Accordingly, this testimony 

addresses (1) whether VA’s clinical productivity metrics and efficiency models provide complete and accurate information on provider productivity and VAMC efficiency and (2) VA’s efforts to monitor and improve clinical productivity and efficiency. In addition, I will highlight four key actions that we recommended in our 

report that VA can take to improve the completeness and accuracy of VA’s productivity metrics and efficiency models and strengthen the monitoring of clinical productivity and efficiency across VA. 

To conduct the work for our report, we examined the types of providers and the 

clinical services captured in the underlying clinical workload and staffing data that 

inform VA’s metrics and models, as well as the processes used to record these data. 

We reviewed VA documentation and interviewed officials from VA Central Office 

and six VAMCs, which we selected based on geographic diversity, differences in facility complexity, and variation in their providers’ performance on VA’s productivity 

metrics as well as variation in the VAMCs’ performance on VA’s efficiency models 

for fiscal year 2015. 3 We examined the monitoring and any related improvement efforts of VA Central Office, the six selected VAMCs, and the Veterans Integrated 

Service Networks (VISN) that are responsible for overseeing the six VAMCs. 4 We 

reviewed VA documentation and interviewed VA Central Office, VISN, and VAMC 

officials. As part of our review, we assessed the completeness and accuracy of the 

information provided by VA’s clinical productivity metrics and efficiency models 

using federal standards for internal control related to information, and we assessed 

VA’s monitoring efforts using federal standards for internal control for information 

and monitoring. 5 Further details on our scope and methodology are included in our 

report. The work this statement is based on was performed in accordance with generally accepted government auditing standards. 

VA’s Metrics and Models May Not Provide Complete and Accurate Information on Clinical Productivity and VAMC Efficiency 

We found that VA’s productivity metrics and efficiency models may not provide 

complete and accurate information on provider productivity and VAMC efficiency. 

To the extent that VA’s productivity metrics and efficiency models do not provide 

complete and accurate information, they may misrepresent the true level of productivity and efficiency across VAMCs and limit VA’s ability to determine the extent 

to which its resources are being used effectively to provide health care services to 

veterans. 

Specifically, we identified the following limitations with VA’s metrics and models: 

• Productivity metrics are not complete because they do not account for all providers or clinical services. Due to systems limitations, the metrics do not capture all types of providers who deliver care at VAMCs, including contract physicians and advanced practice providers, such as nurse practitioners, serving as 

sole providers. VA Central Office officials explained that VA data system limitations and other factors have made it difficult for VA’s productivity metrics to 

capture the workload for all types of providers. In addition, the metrics do not 

capture providers’ workload evaluating and managing hospitalized patients because VA’s data systems are not designed to fully capture providers’ workload 

delivering inpatient services that do not involve procedures-in particular, evaluating and managing patients who are hospitalized. 

• Productivity metrics may not accurately reflect the intensity of clinical workload. A 2016 VA audit shows that VA providers do not always accurately code 

the intensity-that is, the amount of effort needed to perform-of clinical procedures or services. As a result, VA’s productivity metrics may not accurately reflect provider productivity, as differences between providers may represent coding inaccuracies rather than true productivity differences. 

• Productivity metrics may not accurately reflect providers’ clinical staffing levels. 

Officials at five of the six selected VAMCs we visited reported that providers 

do not always accurately record the amount of time they spend performing clinLeonard.horne on VACREP0180 with DISTILLER

26 

6 In its 2012 report, the VA OIG noted that information on productivity can help VA identify 

best practices and those practices that should be changed or eliminated. See VA OIG, Veterans 

Health Administration: Audit of Physician Staffing Levels for Specialty Care Services. 11– 

01827–36. (Washington, D.C.: Dec. 27, 2012). 

ical duties, as distinct from other duties. VA’s productivity metrics are calculated for providers’ clinical duties only. 

• Efficiency models may also be adversely affected by inaccurate workload and 

staffing data. To the extent that the intensity and amount of providers’ clinical 

workload are inaccurately recorded, some of VA’s efficiency models examining 

VAMC utilization and expenditures may also be inaccurate. For example, the 

model that examines administrative efficiency requires accurate data on the 

amount of time VA providers spend on administrative tasks; if the time providers allocate to clinical, administrative, and other tasks is incorrect, the model 

may overstate or understate administrative efficiency. 

To improve the completeness VA’s productivity metrics, we recommended that VA 

expand existing productivity metrics to track the productivity of all providers of care 

to veterans by, for example, including contract physicians who are not VA employees 

as well as advance practice providers acting as sole providers. VA agreed in principle with our recommendation and stated that it plans to establish productivity 

performance standards for advanced practice providers, using available productivity 

data, by October 2017. In its response, however, VA did not provide information on 

whether it plans to expand its productivity metrics to include providers who are not 

employed by VA, such as contract physicians. 

In addition, to improve the accuracy of VA’s productivity metrics and efficiency 

models, we recommended that VA help ensure the accuracy of underlying workload 

and staffing data by, for example, developing training for all providers on coding 

clinical procedures. VA agreed in principle with our recommendation and reiterated 

its existing efforts to improve clinical coding accuracy. It also said that the department would reissue existing policy to VAMCs by June 2017 as well as continue to 

provide need-based, focused coding training to providers, as appropriate. However, 

VA did not provide information on how it plans to improve the accuracy of provider 

staffing data, which inform VA’s productivity metrics and efficiency models. 

VA Central Office Has Taken Steps to Help VAMCs Monitor and Improve 

Clinical Productivity, but Does Not Systematically Oversee Productivity 

and Efficiency across VA 

We found that VA Central Office has taken steps to help VAMCs monitor and improve provider clinical productivity but does not systematically monitor VAMCs’ 

clinical productivity remediation plans and does not require and monitor remediation plans for addressing clinical inefficiency. As a result, VA cannot ensure that 

low productivity and inefficiencies are identified and addressed across VA. Nor can 

VA systematically identify both the factors VAMCs commonly identify as contributing to low productivity and inefficiencies as well as best practices VAMCs have 

developed for addressing these issues. 6

In December 2016, VA Central Office began developing a comprehensive analytical tool to help VAMCs identify the causes of low productivity at their facilities, 

a process that would likely occur after VA’s productivity metrics have identified low 

productivity in one or more clinical specialty at the facility. According to VA Central 

Office officials, the comprehensive analytical tool VA is developing-in the form of a 

data dashboard-is intended to centralize relevant data sources, including data on 

clinic utilization, veterans’ access to care, and provider workload, and thereby allow 

VAMC officials to more easily examine the factors contributing to low productivity. 

The officials told us that they expect the data dashboard to be developed in stages 

and rolled out to all VAMCs and VISNs over the course of 2017. 

While VAMCs are required to monitor VA’s productivity metrics and may take 

steps to improve clinical productivity, VA Central office does not have an ongoing 

process to systematically oversee these efforts. VA policy requires VAMCs to develop 

remediation plans to address any low productivity identified in their clinical specialties and submit these plans to their VISN. Our review found that three of the six 

selected VAMCs in our study were required to develop remediation plans, and officials from these VAMCs stated that they submitted these plans to their respective 

VISNs for review. However, we found that VA’s policy does not stipulate that 

VAMCs or VISNs are to submit approved remediation plans to VA Central Office; 

nor does the policy stipulate that VISNs or VA Central Office must monitor the implementation of these remediation plans to ensure their success. As a result, for exLeonard.horne on VACREP0180 with DISTILLER

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7 VA’s efficiency models are used to track VAMC utilization and expenditures for various 

health care services and compare these expenditures to expected levels. 

ample, officials at one of the VISNs we interviewed told us the VISN does not monitor the implementation of VAMCs’ remediation plans to address low productivity. 

Regarding VA’s efforts to monitor efficiency, we found that while VA Central Office officials encourage VAMCs to monitor and take steps to improve clinical inefficiency at their facilities, VA policy does not require VAMCs to use VA’s efficiency 

models and address any inefficiencies identified by them. In particular, VA has not 

established performance standards based on these models and does not require 

VAMCs to develop remediation plans to address inefficiencies. 7 According to VA 

Central Office officials, VA has not required VAMCs to monitor these models and 

address any inefficiencies because VA officials view the models solely as a tool to 

guide VAMCs in managing their resources. In the absence of a monitoring requirement, we found that two of the six VAMCs we visited had not taken steps to address inefficiencies identified by VA’s efficiency models. 

Based on our findings, we recommended that VA develop a policy requiring 

VAMCs to monitor and improve clinical inefficiency through a standard process, 

such as establishing performance standards based on VA’s efficiency models, and develop remediation plans for addressing clinical inefficiencies. VA concurred in principle with this recommendation, stating that it would require VAMCs to develop remediation plans. We also recommended that VA establish an ongoing process to systematically review VAMCs’ remediation plans and ensure that VAMCs and VISNs 

are successfully implementing remediation plans for addressing low clinical productivity and inefficiency. VA concurred with our recommendation and told us it plans 

to review, twice a year, the progress VAMCs are making in addressing low productivity and inefficiency. 

Chairman Wenstrup, Ranking Member Brownley, and Members of the Subcommittee, this concludes my statement. I would be pleased to respond to any questions that you may have at this time. 

GAO Contacts & Staff Acknowledgments 

If you or your staff members have any questions concerning this testimony, please 

contact me at (202) 512–7114 (williamsonr@gao.gov). Contact points for our Offices 

of Congressional Relations and Public Affairs may be found on the last page of this 

statement. Other individuals who made key contributions to this testimony include 

Rashmi Agarwal, Assistant Director; Michael Zose, Analyst in Charge; Krister Friday; Hannah Grow; and Jacquelyn Hamilton. 

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f 

Prepared Statement of Jonathan B. Perlin, MD, PhD 

‘‘CLINICAL PRODUCTIVITY AND EFFICIENCY IN THE DEPARTMENT OF VETERANS’ 

AFFAIRS HEALTHCARE SYSTEM’’ 

Good afternoon. I’m Dr. Jonathan Perlin, President of Clinical Services and Chief 

Medical Officer for Nashville, Tennessee-based HCA Healthcare. I would like to 

thank Committee Chairman Roe, Subcommittee Chair Wenstrup, ranking member 

Brownley, and members of the Subcommittee for this opportunity to comment on 

VHA Clinical Productivity and Efficiency. 

We are the nation’s largest private healthcare provider, and have the privilege of 

caring for patients through 28 million clinical encounters annually. These include 

approximately 1.65 million hospitalizations, 8.5 million emergency room visits, and 

more than 220,000 deliveries. We number about 241,000 employees, of whom approximately 80,000 are nurses. These numbers are exclusive of nearly 37,000 voluntary physicians. We see patients at 168 hospitals and more than 1,200 other sites 

of care, including surgical centers, free-standing emergency rooms, urgent care, and 

physician offices across 42 markets in 21 states. In other words, we are similarlysized to the Veterans Health Administration. 

We are proud to acknowledge that included in our dedicated healthcare workforce 

are many Veterans and military spouses. We invest in employing service members, 

and in 2016 alone, we hired more than 5,400 military Veterans and 1,100 military 

spouses. In 2015, the U.S. Chamber of Commerce Foundation awarded HCA the 

‘‘Hiring Our Heroes Lee Anderson Veteran and Military Spouse Employment 

Award.’’ 

I believe that I have a unique perspective to offer the Committee, having served 

as Chief Quality Officer, Deputy Under Secretary and Under Secretary for Health, 

as well as - like the Secretary, Dr. Shulkin - as a VA physician during my tenure 

in these roles. 

I appreciate the opportunity to support the work of the Committee and the Department in providing the most effective and efficient care for America’s Veterans. 

In his 100-day briefing at the White House, Secretary Shulkin offered 13 observations on areas he considered risks for VA. He and his team came to these conclusions from both a business and clinical perspective. While there is no need for me 

to recount them here, a few are worth noting, as they are directly responsive to 

some of the concerns that the GAO report identifies. I will augment his observations 

Leonard.horne on VACREP0180 with DISTILLER

29 

with mine, bringing current private-sector perspective on how we manage productivity within our organization. 

Dr. Shulkin’s first diagnosis of risk concerned access. I will not recount all of the 

statistics, but would note that his comments identify substantial progress overall, 

increased same-day access for primary and certain specialty services and some remaining opportunities for improvement. Obviously, increases in provider efficiency 

are an important means for creating additional capacity and access. 

The second area of concern involves prompt payment of external providers. This 

is an area in which legislative relief would be helpful. Consolidation of disparate 

models for obtaining services outside of VA and, frankly, comportment with Medicare or private insurer reimbursement models would facilitate provider participation 

and Veteran access to services. The complexity of the different models imposes statutory inefficiencies in VA’s overall management of care within and outside of VA. 

The third area noted by Dr. Shulkin was quality. VA is to be commended for making their star ratings public. VA is increasingly benchmarking against private sector, and in many instances, VA performance is as good, if not better. I note these 

areas because they are salient to GAO’s central observations on VA provider productivity. 

-GAO first notes that ‘‘Productivity metrics are not complete because they do not 

account for all providers or clinical services.’’ Secretary Shulkin’s recent expansion 

of scope-of-practice for advanced practitioners will both increase productivity and 

present an increasing challenge in recording and benchmarking productivity. Indeed, VA is apt to become the reference point for advanced practitioner productivity, 

to the extent that data systems can attribute the work performed to advanced practitioners individually or in the aggregate. 

-GAO further notes that ‘‘metrics do not capture providers’ workload evaluating 

and managing hospitalized patients.’’ This is a challenge for all entities that provide 

team-based care. The attribution of workload to certain members of the team, beyond the attending physician, is notoriously complex, as has been demonstrated in 

long-standing debate regarding attribution of quality and safety metrics. This is 

demonstrated by, for example, contention over who receives credit for a positive 

quality outcome (for example, a care episode without a vascular catheter infection) 

or blame for a safety breach (for example, a hospital-acquired infection). This is 

problematic because many hands touch the patient, and data systems don’t capture 

every touch. While data systems could be designed for attribution of effort, workload 

needs to be captured as a by-product of work, otherwise it would be inefficient, requiring providers to spend as much time designating their work, as doing their 

work. 

-GAO’s next observation that ‘‘Productivity metrics may not accurately reflect the 

intensity of clinical workload’’ has roots to some degree in the same phenomenon 

- does extra effort required for coding workload compete with actual work and productivity? On the other hand, as VA has announced the decision to re-platform its 

electronic record, this would be an ideal time to consider how to embed tracers of 

workflow that can transparently capture productivity. I would note that in our organization, when we think about the care of hospitalized patients, rather trying to 

capture every individual’s action, we summarize by looking at ‘‘employee equivalents 

per occupied bed.’’ 

- The GAO Report further notes that ‘‘A 2016 VA audit shows that VA providers 

do not always accurately code the intensity of . . . clinical procedures or services. 

As a result, VA’s productivity metrics may not accurately reflect provider productivity, as differences between providers may represent coding inaccuracies rather 

than true productivity differences.’’ Again, documentation improvement to capture 

the patient’s service intensity requirement is something that private sector has become highly proficient in doing, as it is simultaneously the basis for clinical risk adjustment, as well as the basis for graduated payment levels. Similarly, this - and 

‘‘recording (clinician) time performing clinical duties’’ - are area that VA’s new electronic health record should assist with improving. 

-I would agree prima facie with the statement that ‘‘efficiency models may also 

be adversely affected by inaccurate workload and staffing data’’ and that the impact 

may lead to either understating or overstating efficiency. 

-On the basis of my experience with VA management systems of more than a decade ago, as well as my research in preparing for this hearing, I would also agree 

with GAO’s finding ‘‘that VA Central Office has taken steps to help VAMCs monitor 

provider productivity by developing a comprehensive analytical tool VAMCs can use 

to identify the drivers of low productivity.’’ 

-GAO’s exhortation to ‘‘systematically oversee VAMCs’ efforts to monitor clinical 

productivity and efficiency . . . and systematically identify best practices to address 

low productivity and inefficiency’’ is a central challenge for management of multiLeonard.horne on VACREP0180 with DISTILLER

30 

facility health systems across the United States. Certainly, it is a central focus for 

our organization and, in this regard, VA and HCA share an operating advantage: 

Both systems are large enough to look for positive variation. If the underpinnings 

of better performance can be understood, replicated and scaled, it becomes the 

means to elevate the performance of the entire system. 

-Understanding variation within the system and comparison with external performance standards is why both internal and external benchmarking are necessary: 

Internal benchmarking allows systems to tap into the data that they have to identify both positive and negative variation. Internal benchmarking is a tool for learning and management. It can function as one part of a control system for facility, 

VISN and VACO leadership to manage performance. External benchmarking is necessary to understand whether internal performance is superior, consistent with or 

inferior to external organizations. External benchmarking is limited by differences 

in data availability and data definitions among organizations. 

-VA’s ‘‘SAIL’’ system provides elements for both internal and external 

benchmarking, and I would again agree with GAO’s assessment that this is a useful 

management tool for all of the reasons I’ve noted. 

I would note that the biggest challenges to external benchmarking are not related 

to data, but rather certain inherent features of VA and the patients it serves: 

First, Veterans using VA are systematically more complex patients than commercially-insured or even mixed commercial/government-covered (i.e., general Medicare 

or Medicaid) populations. So, some of the external references, such as the MGMA 

(Medical Group Management Association) benchmarks may need to be tempered. 

Better reference environments may be safety net providers, in terms of patient complexity, as well as academic health systems that - like VA - have a simultaneous 

teaching responsibility. 

Second, the VA benefits package is systematically different that either commercial 

insurance or other government programs, like Medicare or Medicaid. VA’s breadth 

of services means that there are more things that a provider can, should and must 

do during a clinical encounter. In a capitated system, it is rational to take all necessary actions for preventive services or other interventions that reduce the need 

for future services or subsequent interventions. Again, the tension between work 

and recording work arises. 

Third, RVU’s were developed for fee-for-service environments and, as such, are intended to make provider compensation proportional to recorded effort. This obviously incentivizes both work and the recording of work. Private sector enjoys different flexibility in provider compensation models, so when clinicians are employed 

by a provider organization, provider compensation can be calibrated to productivity. 

In our organization, we always look at productivity, compensation and quality together. While provider performance on quality is a non-negotiable expectation, we 

can calibrate compensation appropriately. 

Fourth, in our organization, our physical plants and adjunctive staffing models 

are oriented to enhancing productivity. It is systematically inefficient for a clinical 

provider to operate from only one or two exam rooms and with one or fewer support 

staff. My understanding is that despite some spectacular new facilities, VA still has 

opportunity to improve its aged plants and associated staffing models. 

Fifth, there may be times when it is inefficient or inappropriate for VA to internally produce all of the care Veterans need. I agree with the Secretary’s perspective 

to use private sector services when geographic access, wait times, capacity, demonstrated clinical performance excellence or technology are not available in VA. On 

the other hand, VA has demonstrated excellence in serving as a medical and health 

home for the most complex of patients. Indeed, many Veterans using VA are patients with multiple medical and social challenges - such as serious mental illness, 

advanced physical illness, poverty and other vulnerabilities directly related to their 

statutory eligibility for VA care - that challenge private-sector performance and distinguish VA. That continuity-of-care and coordination of services (including medical 

and social) that VA provides is not only special, but not directly replicable in private 

sector. 

Finally, and in closing, it is obligatory to look at productivity and quality simultaneously. Quality and safety are always most efficient: rework for breaches in either 

is neither efficient, nor consistent with the performance excellence that taxpayers 

deserve and that Veterans should expect and have earned through their service and 

sacrifice. Again, my thanks to the Subcommittee for this opportunity, and we look 

forward to working with you and Secretary Shulkin to accomplish these objectives. 

f 

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Prepared Statement of Carolyn Clancy, M.D. 

Good afternoon, Chairman Wenstrup, Ranking Member Brownley, and Members 

of the Subcommittee. Thank you for the opportunity to discuss the clinical efficiency 

and productivity of providers in VA. I am accompanied today by Dr. Murray Altose, 

Chief of Staff for the Louis Stokes VA Medical Center (VAMC) in Cleveland, Ohio. 

VA’s mission is to provide Veterans with the best healthcare they have earned 

and deserve. However, we also must be good stewards of taxpayer dollars, which 

fund this care. This means making sure that our facilities and systems are organized to facilitate optimal productivity and efficiency, particularly on the front lines 

of care. Clinical productivity is the sum of both clinical activity and the effectiveness 

of the team supporting that clinician. This means that a productive and efficient facility has both high-performing clinicians and support staff. 

In 2013, we implemented clinical productivity metrics to measure physician providers’ time and effort to deliver procedures. VA also developed statistical models 

to track clinical efficiency at VAMCs. Data collected under the metrics and models 

are used to identify clinical productivity and efficiency levels. Reports are designed 

to provide leaders in our facilities and networks with essential tools to understand 

which clinics are working under, at, or over capacity. 

Physician Staffing and Productivity Standards 

VA has adopted an activity-based productivity and staffing model for specialty 

physicians. Utilizing an industry accepted Relative Value Unit (RVU)-based model, 

specialty physician productivity standards have been developed and implemented. 

In fiscal year (FY) 2013, productivity standards for six specialties (dermatology, neurology, gastroenterology, orthopedics, urology, and ophthalmology) were developed, 

piloted in four Veteran Integrated Service Networks (VISN) and then implemented 

nationwide. 

A critical component of the productivity and staffing standard implementation is 

the Specialty Productivity-Access Report and Quadrant (SPARQ) tool that provides 

an algorithm for the effective management of VHA’s specialty physician practices. 

This tool is designed to assess specialty physician practice business strategies and 

drive performance improvement in Veterans’ access to specialty care. This tool was 

recognized as one of the most important managerial tools developed in support of 

physician productivity and staffing standards and its ability to go beyond standard 

implementation to ultimately drive system performance. 

The SPARQ tool includes important measures, such as support staff ratios for specialty physicians so as to maximize physician efficiency. The SPARQ tool measures 

the care team, including advanced practice providers such as Nurse Practitioners, 

Physician Assistants, and Clinical Nurse Specialists, and their RVU contribution. 

The SPARQ tool also measures specialty physician value in the form of ‘‘compensation per RVU’’ so as to demonstrate our ability to be good stewards of public 

healthcare resources. 

We are pleased to report measurable progress as demonstrated by increased 

RVUs. VHA’s system-wide focus on improving access to care, prioritizing urgent 

clinical needs and achieving same-day access for Veterans with urgent primary care 

or mental health needs, has resulted in increased clinical output (clinical workload 

up 13 percent) with a concurrent increase in RVUs per clinical employee of 9 percent. 

Government Accountability Office (GAO) Report 

On June 23, 2017, the GAO released a report (GAO–17–480) titled ‘‘Improvements 

Needed in Data and Monitoring of Clinical Productivity and Efficiency.’’ GAO identified limitations with VA’s metrics and models that limit VA’s ability to assess 

whether resources are being used effectively. 

GAO found that productivity metrics are not complete because they do not account for all providers or clinical services due to data systems limitations. The 

metrics also do not capture providers’ workload evaluating and managing hospitalized patients. Also, productivity metrics may not accurately reflect the intensity (the 

amount of effort needed to perform) of clinical workload. As a result, VA’s productivity metrics may not accurately reflect provider productivity, as differences between providers may represent coding inaccuracies rather than true productivity differences. Furthermore, productivity metrics may not accurately reflect providers’ 

clinical staffing levels. GAO found that providers do not always accurately record 

the amount of time they spend performing clinical duties. In turn, efficiency models 

may also be adversely affected by this inaccurate workload and staffing data. GAO 

made four recommendations and VA concurred with each: 

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1.Expand existing productivity metrics to track the productivity of all providers 

of care to Veterans by, for example, including contract physicians who are not employees as well as advance practice providers acting as sole providers; 

2.Help ensure the accuracy of underlying staffing and workload data by, for example, developing training to all providers on coding clinical procedures; 

3.Develop a policy requiring VAMCs to monitor and improve clinical efficiency 

through a standard process, such as establishing performance standards based on 

VA’s efficiency models and developing a remediation plan for addressing clinical inefficiency; and 

4.Establish an ongoing process to systematically review VAMCs’ remediation 

plans and ensure that VAMCs and VISNs are successfully implementing remediation plans for addressing low clinical productivity and inefficiency. 

VA Response to Recommendations 

VA concurred with GAO’s recommendations and is already working to complete 

them. We have already expanded productivity measurement to include Advanced 

Practice Providers (APP) and will establish productivity performance targets for 

them. Since 2014, the Office of Productivity, Efficiency and Staffing (OPES) has 

maintained a comprehensive database of the APP workforce and workload. This 

database, the APP Cube, provides detailed information by discipline about the APP 

staffing levels, clinical workload, and productivity for each VAMC. We collect this 

data and post it on the VHA Support Service Center (VSSC) website. We are currently in the process of establishing standards for these advanced practice providers, 

for whom we recently expanded practice authority across the system. 

We recognize that our current productivity and efficiency monitoring does not represent a 100-percent solution, but it does move VHA toward our goal of ready access 

to high-quality, efficient healthcare for our Veterans. Significant work has been undertaken to improve productivity and efficiency. For example, data tools to assist 

local VAMCs are readily available and are used with increasing frequency. As one 

indicator, the number of web hits on these productivity and efficiency tools within 

the system - which shows local managers are working on initiatives to improve productivity and efficiency - has increased by 37 percent (up from 462,742 to 631,912) 

from the second quarter of FY 2016 to the same time in FY 2017. 

VA concurred in principle with the second recommendation, to develop coding 

training for all providers. VA utilizes appropriate needs-based, focused training to 

minimize the impact on access to care. In May 2016, VHA’s Health Information 

Management (HIM) program office, in conjunction with the Office of Compliance 

and Business Integrity, developed and implemented a process to improve coding accuracy and report monitoring of clinical coders and providers and monitoring productivity of coders. The process includes the appropriate sample size of billable and 

non-billable events per facility along with a standardized data collection tool. The 

facility chief of HIM collects appropriate data, reports results to the facility Compliance Committee and, as appropriate, develops a causation and corrective action plan 

for facility implementation to include focused provider training as deemed necessary. Regular presentations by the Compliance Committee assure leadership visibility of progress in improving productivity and efficiency. The HIM program office 

examines data to identify patterns across VHA sites and develops education remediation efforts. This is then reissued to the field. 

We have also undertaken a comprehensive education and communication plan 

about the specialty physician productivity and staffing standards. We have held national calls to actively engage our specialty physician workforce. Our specialty physicians are committed to demonstrating and improving specialty productivity and 

access. We have also held national calls with medical center leadership in an effort 

to communicate clearly the expectations of full implementation of specialty physician productivity and staffing standards. All medical centers have been provided 

with access to a variety of tools that permit productivity and staffing measurement 

at the individual physician and specialty practice level. Our national and local specialty leaders have been trained on the business strategies and tools available to assist them in managing their specialty practices with the goal of ready access to quality specialty care for our Veterans. 

VA also concurred in principle with the third recommendation, to monitor and improve efficiency through a standard process. The Deputy Under Secretary for Health 

for Operations and Management (DUSHOM) will develop a more comprehensive 

strategy regarding VAMC clinical efficiency by leveraging current clinical efficiency 

models. The DUSHOM’s preferred approach is to continue our present course of enhancing and updating tools that highlight potential opportunities to improve clinical 

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efficiency, and to strengthen the organization’s capacity to disseminate proven, 

strong practices from high performers and, for struggling sites, to provide personalized, on-site assistance. Currently, staff from the DUSHOM’s office sits down weekly 

with field colleagues to identify outlier facilities for follow-up who may have reported unusual increases or decreases in productivity. Plans for improving clinical 

efficiency must be developed at the VAMC. Remediation plans should be tracked at 

both the facility and VISN. The DUSHOM will review the progress VAMCs are 

making on the remediation plans for addressing low clinical productivity twice a 

year with the VISN. The target completion date for this is March 2018. 

Finally, VA concurred with GAO’s recommendation to establish an ongoing process to review and ensure success of these remediation plans. OPES already provides 

ongoing reporting of productivity performance to the VAMC leadership. In addition, 

the DUSHOM will review the progress VAMCs are making on the remediation plans 

for addressing low clinical productivity and efficiency twice a year with the VISN. 

The target completion date for this is October 2017. 

We are currently exploring a productivity measurement system and performance 

targets for Physician Assistants and Nurse Practitioners. This is a complicated matter and involves deliberation with multiple stakeholders who are less accustomed 

to workload documentation than our physicians. Our current Veterans Information 

Systems and Technology Architecture (VistA) data architecture was never designed 

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

needed to assemble an approximation of RVUs. These workarounds introduce a risk 

of reporting inaccurate numbers; and we magnify that risk by expanding the scope 

of measurement. We are encouraged by the fact that the anticipated Cerner system 

is better configured for workload capture and billing using private-sector standards, 

and could help embed workflow indicators that transparently capture data regarding productivity and minimize inaccuracies due to our current workarounds. Many 

private hospitals now rely on integrated applications to reduce coding errors and inefficiency. Capturing the productivity of contract physicians is currently not possible 

because, while we can track workload, we do not have any centralized data for total 

effort or time. 

The 2015 Independent Assessment 

In 2015, the Independent Assessment required by Section 201 of the Veterans Access, Choice, and Accountability Act of 2014 made five similar recommendations regarding productivity and efficiency: (1) VHA should improve staffing models and 

performance measurement; (2) VAMCs should create the role of clinic manager and 

drive more coordination and integration among providers and support staff; (3) 

VAMCs should implement strategies for improving management of daily staff 

variances, and include a replacement factor for all specialties, including Patient 

Aligned Care Teams; (4) VAMCs should implement local best practices that mitigate 

space shortages within specialty clinics; and (5) VHA should improve the accuracy 

of workload capture. 

In response to the Independent Assessment, VA has taken several steps described 

below to ensure increased efficiency and productivity and therefore improve access 

to care and better use of taxpayer dollars. As a result, VA has made great improvements since the publication of the Independent Assessment to improve overall productivity and efficiency. 

As previously mentioned, the SPARQ tool provides data to assist leadership with 

local resource decisions. This includes data on the practice infrastructure and projected clinical workload from the Enrollee Healthcare Projection Model. VHA reports 

provider productivity by specialty and medical center complexity group. Specialty 

practices not meeting productivity targets are required to identify a remediation 

plan, with VA Central Office and VISN leadership actively involved in this review. 

Similarly, Specialty Practice Triggers are in place to identify significant changes in 

clinical workload volume and productivity. 

As a result of the Veterans Access, Choice, and Accountability Act of 2014, we 

have Group Practice Managers (GPM) at all of our facilities who oversee staffing 

and clinic flow. They represent one of the most exciting initiatives that VHA has 

implemented recently. The GPMs are charged with specialty practice management 

and have quickly and adeptly begun addressing the myriad issues in optimizing our 

clinic practice in real time. 

Conclusion 

VA appreciates our colleagues at GAO’s efforts and the efforts of others to improve clinical efficiency and productivity. VHA’s top priority is improving access to 

care for our Veterans; improving productivity and efficiency is a means to that end. 

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Mr. Chairman, I am proud of the healthcare our employees provide to our Nation’s Veterans. Together with Congress, I look forward to making sure that VA will 

be a good steward of taxpayer dollars, while providing this care in a productive and 

efficient manner. Our Veterans deserve this care and our taxpayers deserve to know 

we are providing it in the most efficient and productive manner. Thank you for the 

opportunity to testify before this Subcommittee. I look forward to your questions. 

Æ 

Leonard.horne on VACREP0180 with DISTILLER