```

[House Hearing, 115 Congress]
[From the U.S. Government Publishing Office]

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
       
       
  
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         Available via the World Wide Web: http://www.fdsys.gov
                    
                    
                    
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                    U.S. GOVERNMENT PUBLISHING OFFICE                    
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                    COMMITTEE ON VETERANS' AFFAIRS

                   DAVID P. ROE, Tennessee, Chairman

GUS M. BILIRAKIS, Florida, Vice-     TIM WALZ, Minnesota, Ranking 
    Chairman                             Member
MIKE COFFMAN, Colorado               MARK TAKANO, California
BRAD R. WENSTRUP, Ohio               JULIA BROWNLEY, California
AMATA COLEMAN RADEWAGEN, American    ANN M. KUSTER, New Hampshire
    Samoa                            BETO O'ROURKE, Texas
MIKE BOST, Illinois                  KATHLEEN RICE, New York
BRUCE POLIQUIN, Maine                J. LUIS CORREA, California
NEAL DUNN, Florida                   KILILI SABLAN, Northern Mariana 
JODEY ARRINGTON, Texas                   Islands
JOHN RUTHERFORD, Florida             ELIZABETH ESTY, Connecticut
CLAY HIGGINS, Louisiana              SCOTT PETERS, California
JACK BERGMAN, Michigan
JIM BANKS, Indiana
JENNIFFER GONZALEZ-COLON, Puerto 
    Rico
                       Jon Towers, Staff Director
                 Ray Kelley, Democratic Staff Director

                         SUBCOMMITTEE ON HEALTH

                     BRAD WENSTRUP, Ohio, Chairman

GUS BILIRAKIS, Florida               JULIA BROWNLEY, California, 
AMATA RADEWAGEN, American Samoa          Ranking Member
NEAL DUNN, Florida                   MARK TAKANO, California
JOHN RUTHERFORD, Florida             ANN MCLANE KUSTER, New Hampshire
CLAY HIGGINS, Louisiana              BETO O'ROURKE, Texas
JENNIFER GONZALEZ-COLON, Puerto      LUIS CORREA, California
    Rico

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.
                            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

 
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.
    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 determine 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 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 ratios 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 
Central 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 participation 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.
    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 
efficiency 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 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 space-constrained. Having three or four rooms to 
work with feels like, you know, something from Star Wars. But 
most--
    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 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.
    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 re-platform, 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.
    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 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?
    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.
    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.
    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.
    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 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.]

                           A P P E N D I X

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

    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.
    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 cross-cutting 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.

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.

                                 
             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.
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    \1\ GAO, VA Health Care: Improvements Needed in Data and Monitoring 
of Clinical Productivity and Efficiency, GAO 17 480 (Washington, D.C.: 
May 24, 2017).
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    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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    \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.
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    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.
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    \3\ The 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.
    \5\ GAO, 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.

VA's Metrics and Models May Not Provide Complete and Accurate 
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    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 clinical 
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\
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    \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).
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    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 
example, 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.
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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.
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    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 ([email protected]). 
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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           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 similarly-sized 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 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 multi-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.

                                 
               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:

    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 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.
    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.

                                 [all]
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