[House Hearing, 113 Congress]
[From the U.S. Government Publishing Office]
MEETING PATIENT CARE NEEDS: MEASURING THE VALUE OF VA PHYSICIAN
STAFFING STANDARDS
=======================================================================
HEARING
before the
SUBCOMMITTEE ON HEALTH
of the
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED THIRTEENTH CONGRESS
FIRST SESSION
__________
WEDNESDAY, MARCH 13, 2013
__________
Serial No. 113-8
__________
Printed for the use of the Committee on Veterans' Affairs
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COMMITTEE ON VETERANS' AFFAIRS
JEFF MILLER, Florida, Chairman
DOUG LAMBORN, Colorado MICHAEL H. MICHAUD, Maine, Ranking
GUS M. BILIRAKIS, Florida Minority Member
DAVID P. ROE, Tennessee CORRINE BROWN, Florida
BILL FLORES, Texas MARK TAKANO, California
JEFF DENHAM, California JULIA BROWNLEY, California
JON RUNYAN, New Jersey DINA TITUS, Nevada
DAN BENISHEK, Michigan ANN KIRKPATRICK, Arizona
TIM HUELSKAMP, Kansas RAUL RUIZ, California
MARK E. AMODEI, Nevada GLORIA NEGRETE MCLEOD, California
MIKE COFFMAN, Colorado ANN M. KUSTER, New Hampshire
BRAD R. WENSTRUP, Ohio BETO O'ROURKE, Texas
PAUL COOK, California TIMOTHY J. WALZ, Minnesota
JACKIE WALORSKI, Indiana
Helen W. Tolar, Staff Director and Chief Counsel
______
SUBCOMMITTEE ON HEALTH
DAN BENISHEK, Michigan, Chairman
DAVE P. ROE, Tennessee JULIA BROWNLEY, California,
JEFF DENHAM, California Ranking Minority Member
TIM HUELSKAMP, Kansas CORRINE BROWN, Florida
JACKIE WALORSKI, Indiana RAUL RUIZ, California
BRAD R. WENSTRUP, Ohio GLORIA NEGRETE MCLEOD, California
VACANCY ANN M. KUSTER, New Hampshire
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
__________
March 13, 2013
Page
Meeting Patient Care Needs: Measuring The Value of VA Physician
Staffing Standards............................................. 1
OPENING STATEMENTS
Hon. Dan Benishek, Chairman, Subcommittee on Health.............. 1
Prepared Statement of Hon. Benishek.......................... 24
Hon. Julia Brownley, Ranking Minority Member, Subcommittee on
Health......................................................... 2
Prepared Statement of Hon. Brownley.......................... 25
Hon. Raul Ruiz, Prepared Statement only.......................... 25
WITNESSES
Linda A. Halliday, Assistant Inspector General for Audits and
Evaluations, Office of the Inspector General, U.S. Department
of Veterans Affairs............................................ 4
Prepared Statement of Ms. Halliday........................... 25
Accompanied by:
Larry Reinkemeyer, Director, Kansas City Audit Operations
Division, Office of the Inspector General, U.S.
Department of Veterans Affairs
Larry H. Conway, B.S., R.R.T, Director of Communications,
National Association of Veterans Affairs Physicians and
Dentists....................................................... 5
Prepared Statement of Mr. Conway............................. 28
Madhulika Agarwal, M.D., M.P.H., Deputy Under Secretary for
Health for Policy and Services, Veterans Health Administration,
U.S. Department of Veterans Affairs............................ 7
Prepared Statement of Ms. Agarwal............................ 33
Accompanied by:
Jeffrey A. Murawsky, M.D., Director, Great Lakes Health
Care System (VISN 12), Veterans Health Administration,
U.S. Department of Veterans Affairs
Carter Mecher, M.D., Senior Medical Advisor, Office of
Public Health, Veterans Health Administration, U.S.
Department of Veterans Affairs
MATERIALS SUBMITTED FOR THE RECORD
Deliverables For The Hearing..................................... 36
QUESTIONS FOR THE RECORD
Letter From: Hon. Dan Benishek, Chairman, Subcommittee on Health,
To: Veterans Health Administration............................. 42
Questions From: Hon. Dan Benishek, Chairman, Subcommittee on
Health, Hon. Tim Huelskamp, and Hon. Jackie Walorski, To:
Veterans Health Administration................................. 42
Questions and Responses From: Veterans Health Administration, To:
Hon. Dan Benishek, Chairman, Subcommittee on Health, Hon. Tim
Huelskamp and Hon. Jackie Walorski............................. 43
MEETING PATIENT CARE NEEDS: MEASURING THE VALUE OF VA PHYSICIAN
STAFFING STANDARDS
Wednesday, March 13, 2013
U.S. House of Representatives,
Committee on Veterans' Affairs,
Subcommittee on Health,
Washington, D.C.
The Subcommittee met, pursuant to call, at 10:00 a.m., in
Room 340, Cannon House Office Building, Hon. Dan Benishek
[Chairman of the Subcommittee] presiding.
Present: Representatives Benishek, Huelskamp, Wenstrup,
Brownley, Ruiz, Negrete McLeod.
OPENING STATEMENT OF CHAIRMAN BENISHEK
Mr. Benishek. The Subcommittee will come to order. Good
morning. I want to begin by thanking all of those in attendance
today for joining us at the first Subcommittee on Health
oversight hearing of the 113th Congress.
I am honored to have been selected to serve as the Chairman
of this important Subcommittee and am pleased that Julia
Brownley of California has been selected to serve as the
Ranking Member.
I look forward to working with her and the many new and
returning Members of the Subcommittee individually and
collectively to improve and protect the health of our honored
veterans.
Having served on this Subcommittee before, I know that each
of us shares an immense respect and deep admiration for the
service and sacrifices of American's veterans.
My goal as chairman, in part, is to ensure that when a
veteran accesses health care through the VA, he or she is met
with timely, consistent, high-quality care and services, and is
unburdened by lengthy wait times or unnecessary travel
requirements, and to keep the dollars we spend on VA health
care close to the bedsides of our veteran patients, that is to
say, to prioritize patient care above administrative costs and
bureaucratic overhead that serve the department more than it
serves our veterans.
I was proud to serve for 20 years as a part-time physician
at the Oscar G. Johnson VA Medical Center in my hometown of
Iron Mountain, Michigan. In that capacity, I cared for my
veteran neighbors almost every day. And in the course of that
care, I got to know them, talk to them, and learn from them
about the many challenges and frustrations they face in
accessing health care through the VA.
Here in Washington, I have made it a priority to continue
these conversations with my veteran constituents and I can tell
you that unfortunately their experiences at VA have not changed
for the better.
There are many examples I could provide, through personal
experience and from conversations, examples of veterans who see
a different doctor every time they go to VA for an appointment
and examples of veterans from my district told to travel
hundreds of miles from our home in northern Michigan to the VA
medical center in Milwaukee or Detroit because rules prevent
local physicians from providing needed services in our
community.
I am convinced that these problems are rooted at least
partly in the issue that we are discussing today and that is
the persistent lack of staffing standards at VA medical
facilities.
On December 27th, 2012, the VA inspector general issued an
audit of physician staffing levels for specialty care services.
The IG found that the VA did not have effective staffing
methodology to ensure that appropriate staff is in place to
treat veteran patients at VA medical facilities across the
country.
Since 1981, no less than eight audits and reports have been
issued by either the VA inspector general or the Government
Accountability Office that have recommended VA develop and
implement productivity standards and staffing measures to more
effectively meet patient demand.
Thirty-two years later, alarmingly, little progress has
been made and our veterans are the ones who suffer for it. It
is really unacceptable for those of us on this side of the dais
and I believe it is just as unacceptable for you as well. Today
I am not here to listen to excuses, but I want to hear some
solutions.
I want to thank you all for joining us this morning.
I now yield to Ranking Member Brownley for any opening
statement she may have.
Ms. Brownley.
[The prepared statement of Hon. Benishek appears in the
Appendix]
OPENING STATEMENT OF HON. JULIA BROWNLEY
Ms. Brownley. Thank you, Mr. Chair. And I would like to
really thank you very much you holding today's hearing.
As the new Ranking Member of the Subcommittee on Health, I
look forward to working with you, Mr. Chair, and the other
Members of the Subcommittee and all of our stakeholders to
ensure quality, timely, and accessible health care to all of
our veterans. This must indeed be our mission.
We are here today to address the very important issue of
physician staffing within the Veterans Health Administration.
We know that access to health care is essential to veterans. It
improves treatment outcomes and quality of life for those who
have it. And we know that health care professionals are VHA's
most important resource in delivering high-quality care and
services to our Nation's veterans.
Since 1981, there have been several reports that have
recommended that VA implement measures to assess provider
productivity, staffing levels, and associated resources.
I understand that the wide range of specialties VHA offers
varies in complexity and it is often difficult to quantify the
work that specialists provide day in and day out.
However, in a system with over 152 medical centers and
nearly 1,400 community-based outpatient clinics, it is vital
that VHA is able to establish a staffing methodology to help
evaluate productivity, identify best practices within the
specialties, and develop staffing plans in order to properly
manage resources.
Additionally, with recent veterans returning from war and
becoming eligible for VA services in record numbers, VHA also
needs to be looking toward the future to ensure that all
patients' needs can be met.
I thank all of the panelists for being here today. I am
looking forward to hearing from all of you on how to proceed to
ensure that VA staffing levels are adequate and productivity
levels are sufficient in meeting the needs of all of our
veterans for today and in the future.
Thank you, Mr. Chair, and I yield back.
[The prepared statement of Hon. Brownley appears in the
Appendix]
Mr. Benishek. Thank you, Ms. Brownley.
I would like to welcome our first and only panel to the
witness table.
With us today is Linda Halliday, the Assistant Inspector
General for Audits and Evaluations from the VA Office of the
Inspector General. Ms. Halliday is accompanied by Larry
Reinkemeyer, the Director of the Kansas City Audit Operations
Division for the VA Office of the Inspector General.
They are joined by Mr. Larry Conway, the Director of
Communications for the National Association of VA Physicians
and Dentists.
And finally representing the Department of Veterans Affairs
is Dr. Agarwal, the Deputy Under Secretary for Health for
Policy and Services. She is accompanied at the witness table by
Dr. Jeffrey Murawsky, the Director of the VA Great Lakes
Healthcare System which is known as VISN 12, and by Dr. Carter
Mecher, a Senior Medical Advisor for VA's Office of Public
Health who is seated behind them.
Thank you all for being here this morning and agreeing to
speak with us. It is my pleasure to have you here.
Ms. Halliday, why don't we start with you. Please proceed
with your testimony.
STATEMENTS OF LINDA A. HALLIDAY, ASSISTANT INSPECTOR GENERAL
FOR AUDITS AND EVALUATIONS, OFFICE OF THE INSPECTOR GENERAL,
U.S. DEPARTMENT OF VETERANS AFFAIRS, ACCOMPANIED BY LARRY
REINKEMEYER, DIRECTOR, KANSAS CITY AUDIT OPERATIONS DIVISION,
OFFICE OF THE INSPECTOR GENERAL, U.S. DEPARTMENT OF VETERANS;
LARRY H. CONWAY, DIRECTOR OF COMMUNICATIONS, NATIONAL
ASSOCIATION OF VETERANS AFFAIRS PHYSICIANS AND DENTISTS;
MADHULIKA AGARWAL, DEPUTY UNDER SECRETARY FOR HEALTH FOR POLICY
AND SERVICES, VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT
OF VETERANS AFFAIRS, ACCOMPANIED BY JEFFREY A. MURAWSKY, GREAT
LAKES HEALTH CARE SYSTEM, (VISN 12), VETERANS HEALTH
ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS, AND CARTER
MECHER, SENIOR MEDICAL ADVISOR, OFFICE OF PUBLIC HEALTH,
VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS
AFFAIRS
STATEMENT OF LINDA HALLIDAY
Ms. Halliday. Mr. Chairman and Members of the Subcommittee,
thank you for the opportunity to discuss our audit of physician
staffing levels for specialty services that we issued in
December of 2012.
As you said, I have Larry Reinkemeyer here with me. He is
the director of our Kansas City office that led this audit.
The need for VHA to develop a staffing methodology is not a
recent issue. As early as 1981, GAO recommended VHA develop a
methodology to measure physician productivity. Since then,
several VA OIG and GAO reports have made similar
recommendations.
To date, VHA has established productivity standards for two
of its 33 specialties, ophthalmology and radiology.
In April 2012, VHA assigned a physician to lead the
development of productivity standards and staffing plans for
ten specialties.
Generally, our audit results found there is a consensus
among VHA officials that VHA needs to develop a methodology to
measure productivity. However, a lack of agreement exists
within VHA on the methodology to actually use.
Some VHA officials believe the RVU productivity model is
not a good measure as a stand-alone component for staffing and
other VHA officials stated that based on data availability, the
RVU model is the best model currently available.
VHA lacked the established productivity standards for
specialty care services and as a result, it limits the medical
centers' ability to determine the appropriate number of
specialty physicians needed to meet patient care needs.
An RVU is a value assigned to a service such as a medical
procedure that establishes work relative to the work assigned
to another service. To determine the approximate measure of
current physician specialty productivity, we established a
rudimentary conservative standard by identifying VHA's RVU
median for each specialty care service.
The national median is the middle value among each
specialty care service. Using the median, we analyzed the
collective group of specialty physicians at all VA medical
centers and determined that approximately 12 percent of the
physician FTE did not perform up to the standard.
This translates to just over 800 physicians full-time
equivalents (FTE) representing approximately $221 million in
salaries during fiscal year 2011. Although we did not analyze
the productivity of individual physicians, our results support
the need for VHA to do an in-depth evaluation of staffing.
In addition, without staffing standards, VHA does not have
the internal measure to benchmark productivity within a
specialty. We compared the workload output per clinical FTE for
each specialty care service and found significant differences
in workload. None of the five medical centers we visited could
provide an adequate staffing plan that addressed the facility's
mission, structure, workforce, recruitment, and retention
issues to meet current or projected patient outcomes to address
clinical effectiveness or efficiency.
VHA has not established the productivity standards for all
its specialties because of indecision on how to measure this
productivity. Instead of focusing on the difficulties of
measuring the productivity, the OIG position is VHA needs to
focus on the benefits of discovering the medical facilities
which might be using best practices and identify those
practices that need to be changed or eliminated.
This information is vital to understanding resource
management and making informed decisions. This would maximize
the use of physician resources while increasing access and
quality care to more veterans.
We made three recommendations to the Under Secretary for
Health who agreed in principle with these recommendations. We
expect VHA to establish productivity standards for five
specialty care services by the end of this fiscal year and to
approve a plan to ensure all services have standards within
three years.
Mr. Chairman, this concludes my statement and we would be
pleased to answer any questions you or the Members have.
[The prepared statement of Linda A. Halliday appears in the
Appendix]
Mr. Benishek. Thank you very much, Ms. Halliday. I
appreciate it.
Mr. Conway, please go ahead.
STATEMENT OF LARRY H. CONWAY
Mr. Conway. Good morning, Mr. Chairman, Madam Ranking
Member, and other Members of the Committee.
My name is Larry Conway and I am the Director of
Communications for the National Association of Veterans Affairs
Physicians and Dentists. I am honored to have the opportunity
to represent NAVAPD in that role today.
I also currently serve as the Chief of Respiratory Therapy
Subsection at the VA medical center here in Washington, D.C.
NAVAPD President Dr. Samuel Spagnolo regrets being unable
to participate today. I am presenting NAVAPD's thoughts and
suggestions on developing a viable system for determining VA
specialty physician staffing needs and productivity.
NAVAPD's focus since its inception in 1975 has been
promoting and supporting the highest quality care for our
Nation's veterans and caring for those who provide care for
them.
To that end, NAVAPD supports the development of an accurate
and appropriately administered staffing and productivity
system. This will help assure appropriate staffing levels to
provide the excellent care due to our veterans without undue or
inequitable stress upon the caregivers.
The lack of a unified VA-wide system and the flaws and the
fragmented systems currently in use have led to productivity
assessment models that are not accurate or balanced and which,
in fact, mislead and are useless in determining staffing needs
or performance levels.
NAVAPD became aware of these issues through concerns voiced
by our members over the last two years. And having reviewed the
OIG audit of physician staffing levels for specialty care
services, NAVAPD found that this audit confirms many of the
issues that have been brought to our attention.
The systems being used where any are used are fundamentally
flawed. They are based upon the wrong measurement units. In
some cases, they favor certain staff members while harming or
diminishing others.
For example, these flaws can make one physician, in this
particular case reported to us, a radiology physician for which
there is a system, who performs procedures continually for
their entire shift, appear less productive than a fellow
physician who performs procedures only a few hours out of the
shift. Whether this is accidental or intentional could not be
ascertained.
Regardless, these concerns and the findings of the OIG
culminated an article in the current NAVAPD newsletter. This
article was planned and written before NAVAPD became aware of
this hearing. The article details many of the problems
discussed in NAVAPD's written testimony and the parallel--
findings by the OIG.
Developing a comprehensive staffing and productivity system
for the VA is appropriate and it presents challenges; however,
it is not impossible and should not take a decade to
accomplish. Developing such a system need not be over complex.
It can be tedious, but the assumption of excessive complexity
can be a barrier to progress in the design and implementation.
During my 38 years in management roles across the United
States, I have devised, reviewed, developed, and refined
multiple staffing and productivity systems. I am very familiar
with design options and various methodologies for assessing
health care staffing, needs and productivity.
Beyond selecting and defining the correct measurement
units, the greatest difficulty will be gaining consensus on the
assignment of these measurement units to various procedures.
NAVAPD understands the VA's difficulty in developing a
system and does not seek controversy or confrontation with the
VA; rather, NAVAPD offers its thoughts to the Subcommittee and
its assistance and expertise to the VA in actualizing a useful
and transparent system well within the timeframe that was
recommended in the OIG audit.
Basically, the efforts until now have confused the
relatively simple goal of assessing the number of needed staff
with the factoring of the value of procedures. Determining
required staff is purely a matter of time. Seeking to assess
procedure value introduces many confusing unrelated factors.
The simple one-dimensional time-based relative value unit
was supplanted with a multidisciplinary--I am sorry--
multidimensional unit very much like the unit used by Medicare
that sets dollar values for different services. This introduces
extraneous factors unrelated to the primary goal and including
these factors have been an attempt to assess the required skill
mix of the staff, but it simply multiplies the complexity and
confusion.
As NAVAPD views it, there are three fundamental errors
causing the delays in progress: misconstruction and
misunderstanding of the basic unit of measure, the relative
value unit, which should be purely time-based; second, adding
required skill set procedure difficulty and stress factors to
the RVU; these relate to skill mix which differs from basic
staffing determination; and, three, confusing and interchanging
staffing needs, productivity, and benchmarking systems; each is
distinct, though related to each other.
All of these points touched upon, briefly, in this
statement are discussed more thoroughly in NAVAPD's submitted
written testimony--again, NAVAPD stands ready to assist the VA
in the development of this system.
Thank you for your kind attention. I will be happy to
answer any questions from the Committee.
[The prepared statement of Larry H. Conway appears in the
Appendix]
Mr. Benishek. Thank you very much, Mr. Conway.
I appreciate it.
Dr. Agarwal, please proceed with your testimony.
STATEMENT OF MADHULIKA AGARWAL
Ms. Agarwal. Good morning, Mr. Chairman, Madam Ranking
Member, and Members of the Subcommittee.
Thank you for the opportunity to testify, and I submit my
written testimony for the record.
I am accompanied today by Dr. Carter Mecher, of the VHA's
Office of Public Health and Dr. Jeffrey Murawsky, Network
Director of Great Lakes Health Care System.
It is essential to ensure that VHA's physicians are able to
work as effectively as possible to meet the needs of veterans.
It is my privilege to inform the Subcommittee of the actions we
are taking to ensure that our physician workforce is optimally
deployed.
The foundation of our integrated health care delivery
system is primary care; therefore, primary care physicians were
our first priority for developing a staffing model. These
providers constitute 34 percent of our physician workforce.
Our fully operational--operational primary care panel
staffing model defines the number of active patients that may
be assigned to each primary care provider and our model
balances productivity with quality, access and patient needs,
and permits VHA to measure the productivity of primary care
providers and the capacity of our system.
Psychiatrists, the second largest component of our
physician workforce, now account for 14 percent of VA
physicians. We will be providing productivity and staffing
guidance for mental health providers of spring this year.
Mr. Chairman, the contrast to a panel-based model, relative
value units, or RVUs, are used by many academic and private
institutions to track specialty care physician productivity.
Work RVUs consider the time and intensity of physician
services.
In academic and in private practices, work RVUs are used to
determine the practice and physician compensation; therefore,
these practices have a significant investment in capturing the
workload and coding, including support staff as the RVUs, sir,
to optimize billing.
We currently use RVUs to determine productivity standards
for radiologists, the third largest component of the physician
workforce. And by late spring, more than 54 percent of VHA's
physician workforce will have standards to measure their
productivity and efficiency.
VHA intends to expand the use of work RVUs as one of the
measures to assess the productivity and efficiency of the
specialty practice areas throughout the organizations.
Productivity standards are an essential component, but require
other contributing factors such as support staff, capital
infrastructure, and patient needs to determine staffing levels.
VHA's Office of Productivity Efficiency and Staffing, also
known as OPES, has created a Physician Productivity Cube to
determine the productivity workload for physicians specialties
by measuring the workload through work RVUs, number of
encounters, and number of individual patients.
In June 2012, VHA established a specialty care physician
productivity and staffing plan task force. The task force has
focused on seven specialties: cardiology, gastroenterology,
dermatology, neurology, orthopedics, urology and ophthalmology.
Its recommendation was for an RVU-based approach that builds
upon the extensive work that OPES has already done in this
area. OPES is testing and refining new solutions for capturing
workload that do not impose additional burdens on clinicians
who are treating veterans and will take into account the unique
characteristics of local facilities.
VHA is also integrating the physician productivity data and
measure of access to care into a model to guide staffing
decisions in specialty care. This approach, when coupled with
measures of quality and amount of specialty contract care, will
help VA medical centers' leadership make informed decisions
regarding staffing.
We intend to establish productivity standards for five
specialties by the end of this fiscal year and we will ensure a
plan is in place to establish productivity standards for all
specialty care services within three years. We are providing
specific training to the leadership of our health care
facilities on how to use the data from the Physician
Productivity Cube and we will provide the medical facility
leadership more specific guidance on how to develop staffing
plans so that management reviews them annually to ensure
optimal efficiency.
Mr. Chairman, we appreciate the opportunity to appear
before you today. My colleagues and I are prepared to answer
your questions.
[The prepared statement of Madhulika Agarwal appears in the
Appendix]
Mr. Benishek. Thank you. I hope that we have a vigorous
round of questions here. I'm going to start by yielding myself
five minutes for questioning.
Speaking with physicians at various VHA medical centers,
I've heard different reasons for, difficulty with productivity,
and--in the IG report, on page 4, there was endocrinology
clinics where an FTE produced 3,000 patient visits a year and
another facility, that was twice as productive, for the same
amount of time and within the same specialty.
So, as I understand it, Ms. Halliday, you didn't really
look into the reasons for the productivity differences between
different facilities that were supposed to be comparable. Do
you know the reason why one unit is twice as productive as the
other?
Mr. Reinkemeyer. We tried to stay away from looking at the
individual inefficiencies or efficiencies of a physician. The
point we tried to make is there could be lots of reasons why
that is occurring.
As we talked the other day, it could be support staff.
Maybe these physicians do not have the adequate support staff
they need, and maybe they are checking patients in, or having
to do a lot of the administrative tasks, which is decreasing
their productivity.
There could be more negative reasons as well, but what this
does is give the director that tool--and I would hope the
director would want that tool--to identify best practices and
efficiencies.
Mr. Benishek. Mr. Conway, do you have any input to that? It
seems to me that there may be circumstances that make a
physician less productive. You work with that group.
Mr. Conway. Yes, Mr. Chairman. There certainly are factors
that make physicians more or less productive. We have heard
from our members of scenarios where a clinic, for example, is
operated where each physician has one exam room, no support
staff. They have to go get the patient, register the patient,
pull up the chart, do the vitals, do the physician review,
remove the patient from the room, and finish their charting,
and any other support documentation necessary; whereas, other
particular facilities may have staff available to prep the
patient for the physician, provide more than one exam room--as
would happen in a private practice--and thereby increase the
throughput by one physician.
So, we know those type of variables exist. I would also
note that this section of the report speaks of encounters. We
are not clear at NAVAPD of how an encounter is defined. An
encounter could be something as simple as a quick review that
might last four or five minutes. It could become something much
more complex that lasts 20 or 30 minutes.
A term as broad as encounter----
Mr. Benishek. Right.
Mr. Conway. --without an attached timeframe is useless in
determining either staffing needs or productivity.
Mr. Benishek. Dr. Agarwal, you know, these kind of
questions, bother me. The reason I am doing this is that,
people have told me that I go to the VHA for my congestive
heart failure and I see a different physician every time, that
concerns me that that patient is not getting the best of care
because when you have congestive heart failure, you have to
have a provider that recognizes how much edema you had in your
legs last week and how short of breath you were. And when you
have a different physician seeing you, they can't make that
judgment. And I can't tell from what you are saying, what the
IG is saying, and what the actual physicians are saying.
Do we have a standard way to run a clinic--where there are
four exam rooms and--and a physician has adequate opportunity
for example--or is it up to the individual medical center? Is
there no standard way of running a clinic?
Ms. Agarwal. Sir, thank you for that question.
Sir, let me answer it in two ways. First is that the VHA
has adopted a model, which is sort of based on the patients at
a medical home and we call it PACT, the Patient Aligned Care
Teams, which is the initial entry for most patients with
chronic illnesses, such as congestive heart failure.
And the idea is that they would be provided full
comprehensive care with continuity of care in that PACT Team,
and when they need a specialist they would then see a
specialist. So, I am somewhat surprised that a patient who has
been assigned to one of the PACT Teams is not seeing their team
on a consistent basis--and I will certainly look into it--but
that is--that is the goal. When it comes to referring to the
specialist, I think most of the specialties are doing what they
can do best, which is taking care of the patients for that
particular episode.
So, it is likely that if for this patient that you are
mentioning or the clinician who is not being able to see their
own physician all the time is also perhaps going to different--
other specialties, as well, and I cannot ascertain that right
now.
Mr. Benishek. Well, that is disappointing. I don't like the
fact that we don't have an answer. Apparently, right now,
physicians are seeing patients slowly in one hospital and then
maybe more effectively in another because of the staffing
issues within their clinic. This is something I would like to
further explore, but my time is up and I would like to give the
Ranking Member an opportunity.
Ms. Brownley. Thank you, Mr. Chairman. And thank you to the
panel for your testimony. You know, as a new Member of
Congress, which I am to have read this report and to see that
we have been working on this for 30 years--and are still
wrestling with it is just really astonishing to me--it's
shocking--and it seems that this kind of thing is the thing
that sort of underscores what the public feels in terms of
Government being inefficient and perhaps wasteful.
And, certainly, for our veterans who have served our
country, it is clear, the outcomes here are that our veterans
are being served on a timely basis and have consistency with
the same doctor to get the quality of care that he or she
deserves.
I guess I wanted to ask Dr. Agarwal.
Ms. Agarwal. Yes, ma'am.
Ms. Brownley. Can you speak to how the VHA really compares
with productivity of the private sector?
I know the private sector has got to have best practices
established. I know that the private sector is generally for
profit and the VA is not, but are there any comparisons that
you can speak to?
Ms. Agarwal. Madam, thank you for that question.
And you are absolutely right in pointing out that we have a
different practice model. We, as compared to the private
practice, we serve more as a capitated or HMO-like setting with
salaried positions. So, our productivity levels are best
measured by like specialties and like facilities with that
appropriate staffing mix.
In the private sector, as I mentioned previously in my
testimony, the RVUs, the work RVUs especially, are generated,
which are also something that contributes strongly towards the
compensation.
Now, that is not the case in VHA. Our goal is primarily to
achieve the best health care outcomes for our veterans and that
is where we focus, not in the volume of services, but in
providing the right services at the right time in the right
place.
So, I am just going to ask my colleague, Dr. Murawsky to
expand, if he would.
Mr. Murawsky. So, in running the health systems and in
evaluating how we--operational, as our clinics--we look at
productivity as one component of a multifaceted decision-making
process, to evaluate what we are doing so productivity drives
the comparisons with--the private sector have the disadvantage
for us in that their selection for what work to expand is based
on what RVUs bring in the highest per time, where we look at
the whole patient, and so we don't want to be ignoring one area
because it is a low RVU generator for another. So, we use it
internally to benchmark it against ourselves. Comparing for, as
has been mentioned before, the practice setting, the support
staff ratio, those things are critical, physical plant design
also drives what you can generate.
Physician productivity is also linked to what a facility
can accomplish. We see lower levels of productivity in pure
RVUs. If you try to compare a very small facility to a very
large facility, the opportunity for a physician to do high RVU
work in a small rural hospital is less than in a large tertiary
hospital because of the support systems needed to do cardiac
bypass surgery. The high RVU specialties just are not going to
be present.
Ms. Brownley. Well, it seems to me that some of the
challenges here, and it seems like the challenges are very
clear, they are laid out--but one of the challenges is trying
to find, in essence, sort of consistency and continuity over
all of these different practices which may, indeed, be
impossible to do. I mean, there are doctors on this dais that
know more about this than I do. I agree with you that the goal
should be the outcome of the patient, making sure that they
have the timely and right services when they need them, but why
are we not looking at that kind of measurement, as opposed to
trying to measure all of these things?
At the end of the day, we can be as efficient and
productive as possible, but if a patient remains sick or dies,
we are not achieving what we want to accomplish here. So, I am
just wondering why we are not looking at this a little
differently.
Ms. Agarwal. You are absolutely right.
You know, I think to compare each of them against each
other--the specialties, I should say--would not be a good idea
at all. In fact, one of the reasons why we set up this task
force was to set up those standards for each of the specialties
of its own. Because it is only fair to compare one specialty--
let's take cardiology as an example to another cardiology--but
then even cardiology between two facilities may not be the same
if they are on different levels of expertise.
One facility may provide more interventional procedures, as
opposed to another smaller, perhaps, rural facility that is
only going to provide, likely, outpatient work.
So, the comparisons have to be fair and they have to be
done within the like specialties and that is what the goal of
the task force has been, to first identify that, you know, RVUs
were whatever we may want to say that how imperfect or perfect
they are, but they are currently one measure that is used as an
outside benchmark, and be used to use--take that and start to
compare and use our methodologies to create certain business
rules, so that the workload capture is common and accurate, the
present class designation in our systems is accurate for those
specialties, and the support staff, which is a very important
component of getting to the final idea of having a staffing
plan, are all taken into account when we put forward a plan to
do this.
Ms. Brownley. I yield my time.
Mr. Benishek. Thank you, Ms. Brownley.
Next for questions, we have a Member from Ohio, Mr.
Wenstrup. Thank you.
Mr. Wenstrup. Thank you for your time. Thank you, Mr.
Chairman. You know, as somebody who has served in the Army
Reserve, I have been in DoD facilities. Virtually any doctor in
America, who was trained in America, has been in VA facilities
and received their training there; it is an important part of
our medical system.
And I have also been in theater, but also in civilian
practice, and my take is that the huge difference is in your
own practice, you have to be efficient or you close your doors,
and that is the difference. And my experience has been that you
have doctors doing so much administrative work, that it cuts
into the time that they can see patients and there is your
backlog. Literally, in the time that I can see 45 patients in
my civilian practice, in another facility, such as this, I
could see about 15. And the doctor is doing work that a 16 year
old could do at minimum wage, and this is part of the problem.
I applaud you for breaking it down by specialty, because it
is different, and even within specialties, it can be different.
My question to you is: Are you looking at it that way? Are
you breaking it down and saying how efficient are we making the
provider of care and are we having them doing things that other
people could do for virtually next to nothing?
And, you know, a lot of your doctors come from civilian
practices and give a couple days a month or something like
that--some of my partners in orthopedics have done that--and
they will say where I do six surgeries in civilian practice, I
can do two at the VA.
This is a fundamental problem. Maybe it is work ethic and
maybe it is how the system is set up--maybe it is both--and I
would like to hear where you are going with it from there,
because the answers are fairly obvious to me.
Ms. Agarwal. Sir, thank you, again, for that question--
actually a very important question. And you are right and I am
going to ask my colleague, Dr. Murawsky right after I finish,
to add more to it.
So, our statutory mission is, of course, to provide direct
patient care. But it is also to provide education and training
for the medical students and the residents, as well as to
provide cutting-edge research so that we can benefit the
veterans, and the fourth role is emergency preparedness.
What is also critical is that we appropriately apply our
labor mapping to distinguish on the role of a given position,
and that is also very important. Suppose if someone is to give
100 percent direct patient care, then that is how it is mapped
back into the system. If someone is going to be providing
training to an education--to the residents or the medical
students who are coming in--that they are given credit to that
end as well.
So, those are some of the factors that we are working on
and the task force that is currently in play with the four
pilots and the four reasons that are going, are also looking at
these contributing factors to the productivity and how do we
optimize and bring them to their fullest efficiency that we are
all seeking. So, the methodologies of how we do this are
critically important.
I am going to ask Dr. Murawsky to sort of follow on that.
Mr. Murawsky. Thank you, and thank you for the question.
It is a complex system--and coming from private practice
before I came into the Department as a medical educator, we
need to make sure as we develop our pilots, and as the task
force does that, we look at the inefficiencies gained by our
training mission--which all attending physicians know,
residents can slow you down--so, we need to capture that. And
since we have such a high number of trainees, that is a unique
part of our mission, so when we make our comparisons, we have
to add that.
We started to look at support staff, and I know from
experience within Network 12, we started to look at that
component. When we looked at research requests, what is the
support staff ratio? What should it be? Are there external
benchmarks that we can compare to?
The task force is trying to bring that in through the
pilot, so that when we take productivity and create the
algorithm to develop staffing, it pulls those components in so
we get that optimal level of efficiency.
We also trust our staff members to look at--are there
things in the encounter that they are doing that are
inefficient that we need to make better? So, we are trying to
decrease that burden.
And one of the things I can speak to as a provider, is that
I lost a lot of burden of my billing and coding when I came to
the VA. The encounter is a much simpler method that we have
internally than the time that I used to spend trying to capture
that revenue before I came in. So, there is some switch. We
just need to capture how much that is and then gather those
inefficiencies and look at it across, not just the practice
setting in the outpatient area, but in our surgical area for
our surgeons, can the ORs turn quickly enough? So, we have to
capture all of that in the decision-making process.
Mr. Wenstrup. And I appreciate that, and I would be the
first to agree that when you are training, it takes more time
than if you are just seeing the patient individually. I think
you have got the right parameters, it is just how we implement
them and how we get that done universally.
And I yield back.
Mr. Benishek. Thank you, Mr. Wenstrup.
I now yield to my colleague from California, Dr. Ruiz.
Mr. Ruiz. Thank you, Chairman Benishek and Ranking Member
Brownley, for holding today's hearing.
I am looking forward to learning more and having more
discussions about productivity within the Veterans Health
Administration.
It is very important for me, coming as an emergency
medicine physician both in the private sector, as well as the
academic sector, being a Senior Associate Dean at one of the--
California's newest medical schools, UC Riverside School of
Medicine, I know the importance of RVUs for a physician. Often
times, we practice medicine and a lot of our reputation lies on
who has seen the sickest and the most complicated patients and
for emergency medicine physicians, that is a source of pride.
But it is also a source for incentives on how you practice
medicine, because, usually, productivity equates to
compensation, and therefore, it is all too easy, sometimes, to
add an extra box on the EMR or add an extra section on the
social history in order to beef up your medical record to get
paid more. And it is also, often times, too easy to add and be
incentivized to order another test that you might not need to
order because it adds to compensation.
And I think that Ranking Member Brownley mentioned the
incentives that we want to change is not only to order more
tests, but also to keep what you mentioned, patients healthy,
so we don't have to order these expensive tests.
So, one of my questions to you is: In your productivity or
compensation model, how are you incentivizing a healthy
patient, keeping them from acquiring and getting sick for end-
stage congestive heart failure?
Ms. Agarwal. Again, an excellent question, Congressman. Our
compensation is somewhat different from what it is in the
private sector. Most physicians in the VA are salary positions
and I, you know, I can talk about the three parts of the
compensation package but they are largely not incentive-based
in that sense.
But incentives really have to be that our goal and our
mission, for those of us who come in to serve in the
organization, is to be very proactive and offer personalized
patient health care.
So, I will, again, emphasize the fact that as the others
are doing so, in ABIM's Choosing Wisely campaign, that it is
not how much that we are going to offer, but how well and how
wisely we are going to choose the services that are going to
keep our patients healthy going forward. And that is sort of
the mantra and the principle that we have for ensuring that the
right services are provided without any real financial
motivators, I would say.
But, again, the third component of the physician's salary
is the performance pay, and I can ask Dr. Murawsky as to how he
goes about setting that up in his network.
Mr. Murawsky. Thank you. The two base components that make
up the predominance of pay, up to 7.5 percent above that, is a
performance pay, individually negotiated between each provider
and their supervisor. There is some general guidance around
performance pay. It is used to improve your practice.
In most cases, within our network--within the network
that--that we have in Chicago and up to the Iron Mountain area,
we look at quality metrics as what we use to drive that
particular component of pay.
It might also be access metrics if there are issues we want
to drive around access to care. It could be new service
delivery; if we want to add a service or reduce a service, we
will add that.
In some cases, we use productivity levels in a very broad
sense if we believe that they might be low in an area. We use
them in radiology, as an example, for the practice, but not for
an individual. Can the practice maintain a certain level of
productivity?
We find that if we have our physicians work together in
those groups, those incentives that can be perverse tend to
wash away because there is not an individual trying to get
ahead of another one, so we tend to orient it that way.
Mr. Ruiz. Do you factor in the Press Ganey and patient
satisfaction into that?
Mr. Murawsky. Yes, sir. There are a number of VA specific
scores. We have a--in primary care there is a particular
outpatient survey that is used. HCAHPS and CAHPS scores for the
practice area can be--can be used in that area. Our physicians
find that sometimes the data lags at such a point that it is
not there.
So, I know that in areas where we receive veteran concern--
I have one example in a network within the facilities of my
network where we did a postcard program, where, basically, we
said how many postcards said we did a great job; how many
postcards said we did a poor job; let's see if that changes
over the year. We incorporated that.
Mr. Ruiz. I know my time is up.
My final comments are essentially to see if we can move
away from an incentive that fosters expensive tests and
complicated uncoordinated management of patients and more
towards incentivizing the prevention and the outcome so that
our measure of success is not how many MRIs and cardiac caths
we do, but it is how many heart attacks we prevent from
happening. So, the longevity and the wellness of our veterans
is first and foremost, above anything else.
And I thank you very much. I know it is a very difficult
job and I appreciate all you do, and I yield back my time.
Mr. Benishek. Thank you, Doctor.
Next, we have the gentleman from Kansas, Mr. Huelskamp.
Mr. Huelskamp. Thank you, Mr. Chairman.
I appreciate the opportunity to be here today and to look a
little more closely at this issue.
The first question would be directly to the VA, and given
after 32 years of efforts, there seems to be a lot of
inconsistency in determining staffing and those issues. So,
what is unclear to me is how do you currently measure the
productivity of your physicians to determine staffing levels?
Ms. Agarwal. So, sir, for primary care, it has been
something that has been in place regarding a panel model and
that is about a third of our patient physician workforce.
We have done the same for radiology, on determining what
their duties--standards should be.
We have guidance that is coming out for mental health very
soon and that will constitute about 14 percent of the physician
workforce--that covers about half.
What we are currently working on now is to set standards
for five specialties by the end of this fiscal year, and to
that end, there are pilots that have started in four networks,
in VISNs 7, 12, 19, and 22.
And the purpose of----
Mr. Huelskamp. If I might interrupt on that.
Are you telling me that the primary care physicians, you
have an adequate standard for determining proper staffing
levels?
Ms. Agarwal. Yes, sir, we do; for primary care, we do.
Mr. Huelskamp. That seems somewhat different than what I
saw on the IG report. But one thing I will ask, pretty specific
to my district, I do have a community-based outpatient clinic
that has been without a physician for over two years. Can you
tell me how do you determine what clinics do not need a
physician at all or even a nurse practitioner, is there a basis
for making that decision?
Ms. Agarwal. Sir, I do not know of a primary care clinic
that would not have either a physician or a nurse practitioner.
Mr. Huelskamp. There must have been some lost information.
Again, December 20 of 2011--actually, it is a little over a
year, I guess, a nurse practitioner for over two years or not a
doctor since December of 2011 still has no--in a clinic in
Liberal, Kansas.
We have asked the VA again and again, and I just didn't
know how you determine that there will be no primary care
physician or a nurse practitioner in this community-based
outpatient clinic. So, I look forward to your response on that.
But other than that particular area, I am still struggling.
After 32 years, the IG report would suggest that we have not
solved this situation. But you believe that within how long it
will be solved, out of the primary care into the specialty-
physician level, that will be solved or be adequately addressed
in what time period?
Ms. Agarwal. Within three years, sir. We will have
standards for all specialties in three years.
Mr. Huelskamp. Okay. A law passed in 2002, and so we are
going to take 15 years to implement that law or do you think
that you are currently implementing that requirement of the
2002 law?
Ms. Agarwal. Sir, we have been working on it, sir.
The creation of the office of productivity and efficiency
was in 2008 and that was mostly to sort of ensure that we have
some strategy to manage this important resource. They have been
developing certain tools for it, so it has been a work in
progress.
Mr. Huelskamp. Do you think that 15 years is an adequate
time period to--again, January of 2002 is when that law was
passed, is my understanding.
Ms. Agarwal. Sir, it has been longer than one would have
anticipated, but we--at this time, what I can assure you is
that it will be completed in three years.
Mr. Huelskamp. Mr. Chairman, that would be very helpful,
but I think I would be quite foolish to anticipate that if you
could not get it done in 11 years, 12 years, that three more
years is going to make that happen.
And, again, I look forward to your response, specifically,
to how an outpatient clinic that has no primary care staffing,
and I don't know how you all made that determination.
And we have not had an answer back. I have been asking
again and again from the VA and there has not been a good
reason--just saying, hey, we are not doing that.
So, I yield back, Mr. Chairman.
Mr. Benishek. Thank you, Mr. Huelskamp.
And I will, of course, expect follow-up answers, after you
get some information in.
Ms. Agarwal. Yes, sir.
Mr. Benishek. --but I was interested by your questions, as
well. Next, we have Ms. Negrete-McLeod from California.
Ms. Negrete-McLeod. Since I came in late, I don't want to
ask questions that have already been asked.
Well, I guess I was going to ask the same thing that it has
taken ten years to implement what has been mandated by law and
I am just wondering--following up on the question of why it is
taking so long.
Ms. Agarwal. Madam Congresswoman, this is somewhat of a
complex issue, as our testimony has indicated. It is not very
simple.
And especially given the fact that we are a capitated model
and not a fee-for-service, where, you know, much of this would
have already taken place about capturing the workload and
comparisons and so on and so forth. We have been working on it,
but we also realized that to have appropriate staffing, we need
to have certain standards in place and the work is underway to
complete that.
We have done the staffing standards for roughly 54 percent
of our physician workforce and the remainder is going to be
completed within the next three years.
Ms. Negrete-McLeod. I guess, then, I would ask that, I
understand that you have a very large organization, you know,
overall, but I think that ten years is really a long time and I
think, I am just wondering if you can assure us that you are
going to do it soon, then we would take your word on that, that
it would be implemented soon.
Ms. Agarwal. Thank you.
Mr. Benishek. I would like to ask members of the IG staff
to comment on the answer that VA gave to Mr. Huelskamp and Ms.
McLeod.
Ms. Halliday. I would be happy to.
The law that you are citing, talks to having to ensure that
the medical facilities have adequate staff to provide high-
quality care.
Right now, you constantly hear that there are waiting times
and those type of issues that veterans cannot get to their
appointments that are impacting their view of whether they can
even get care.
In our report, we have a recommendation to the Under
Secretary to provide specific guidance on how to develop the
staffing plans and to ensure medical facilities actually review
these annually to optimize their efficiency.
When our team went out, teams went out to the five
facilities, we saw significant inconsistencies in the types of
staffing plans that were maintained. That is the piece that, I
believe, sir, you were talking about.
Mr. Benishek. Mr. Conway, do you have any comments?
Mr. Conway. Yes, Mr. Chairman.
A number of things have come forward in the last few
answers, actually. There is continuing reference to high RVU
work which means that for the same period of time it is valued
higher. That is a model--that is a metric that is more
consistent with a fee-basis or a for-profit type environment
where you are saying that this 30 minutes of time during
neurosurgery is more valuable than 30 minutes suturing a hand.
It does not deal with the issue of how much staff it takes to
do it. It is a different kind of metric that confuses the
issue. And those kinds of--those kinds of disagreements are a
part of what has pushed this development back so far.
There was also a reference to incentivizing and performance
pay being part of the incentive package. But, again, if you
have a productivity model that inappropriately makes certain
staff members look less productive when they are not, that
affects performance pay in a way that disincentivizes, rather
than incentivizes.
Again, I think that--that maybe that underlying message is
to keep the metrics simple so that you can truly assess what
you need, which is the amount of staff it takes, and then,
conversely, how much work is being produced with a given level
of staffing, which is the definition of productivity, and we
are introducing factors in the current system that--that simply
cloud the issue.
Should it take ten years? Absolutely not. Are there for-
profit organizations that has a system that does exactly this
today? Yes. Would they share them with you? I doubt it. Should
you apply them to the VA? No, because the VA model is
different, the patients that we serve are different, and our
goals are different.
That having been said, there certainly is no reason to not
be able to develop a model that gives you adequate staffing
assessments and adequate productivity assessments.
Mr. Benishek. All right. Thank you.
I think we are going to have time for another round and I
have a couple of follow-up questions that I am going to start
with.
Frankly, I am a little disappointed.
And I know, Dr. Agarwal, you have not been here this whole
time in this position, but the fact of the matter is that, for
30 years, VA has been struggling with, not having an overall
plan, with, issues such as the fact that there is no standard
way of conducting a clinic, with different--with time
requirements--with inadequate support staff, and, some of the
reasons that you have given, really don't wash.
I have practiced in a rural VA hospital and I think Iron
Mountain did it really well. We had four or five exam rooms. I
was able to see patients. In the surgery clinic, when I was
there, we could see them very efficiently, just as efficiently,
I thought, as it was in private practice.
And, frankly, I think we improved the efficiency in the OR
by having the physicians comment on how it should be done and
why we improved the efficiency of the OR a great deal.
I am just afraid that there is so much inconsistency, that
there is no overrule all plan. My biggest concern is the fact
that our veterans are suffering because there is inadequate
staffing. I know in the upper peninsula, people have to travel
some time because we don't staff Iron Mountain hospital enough.
They then have to get on a bus to go hours on a bus to
Milwaukee for a specialty clinic visit that could have been
done in Iron Mountain. Ten hours on a bus for a 20 minute
specialty clinic appointment seems like not the best use of the
veteran's time or VA's dollars.
Do you have any idea of what the staffing standards are for
the patient's travel time or for the overall cost, Dr. Agarwal?
Ms. Agarwal. So Chairman, thank you for that question.
There is one thing that I should point out is that one area
that you readily, and have pointed out to me, is the travel
time and what it is that one can do about that. And to that
end, our telehealth services have been expanding, which is,
again, so that we can provide the care much closer to the home
from the specialty services which may not reside in that
facility.
And I think I will ask Dr. Murawsky to speak more about
what goes at Iron Mountain and the travel time thereabouts.
But I think VHA has taken a position about--about providing
the best care possible and the most optimal place, which would
be closest to the home, whenever possible. And telehealth is
one of those technologies that is sort of helping us achieve
that now, and especially in specialty care areas there are a
couple of models that are happening.
Mr. Benishek. Well, I can see that where you are kind of
diverting the answer, because telehealth is not going to be an
answer for----
Ms. Agarwal. No.
Mr. Benishek. --many of the----
Ms. Agarwal. So----
Mr. Benishek. --many of the problems that we are talking
about----
Ms. Agarwal. Right.
Mr. Benishek. --because, otherwise, they would have done
it. I am just not happy with the fact that, we are waiting
another three years after 30 years of beating around the bush
it seems; whereas, in the private sector, this seems to move a
lot faster.
Let me yield to the Ranking Member, once again.
Ms. Brownley. Thank you, Mr. Chair. I just wanted to
follow-up with Dr. Agarwal on what our colleagues have
expressed today on the dais. And you have said, repeatedly, in
your testimony today that in three years you will have a plan
to accomplish these measurements and these goals.
At this moment in time, do you have a plan that is on a
piece of paper that demonstrates how you are going to
accomplish this over the next three years?
Ms. Agarwal. Yes, ma'am, we would be happy to share that
with you. We, certainly when we started the task force last
year, that was the intention, and after they briefed the
leadership, they have sort of proceeded on with the pilots. The
data that they are getting is going to help us establish for
the five specialties within this year and by the end of this
fiscal year, we will have a plan on how to complete the
productivity standards for all specialties by the end.
Ms. Brownley. So, you are saying all specialties by the end
of----
Ms. Agarwal. Three years.
Ms. Brownley. --three years? Okay.
Ms. Agarwal. Yes.
Ms. Brownley. All right. Well, I would appreciate it if you
could share the plan, and I presume the plan has timelines in
it so that we can monitor your progress?
Ms. Agarwal. We will make sure that--we will have the
timelines.
Ms. Brownley. Very good.
You know, after ten years, 30 years, there is a reason for
us to have some skepticism----
Ms. Agarwal. I understand.
Ms. Brownley. --just wondering how many people have sat in
your seat over the last 30 years and said, I am assuring you
that I will get this done in three years and we really do want
to get it done.
I wanted to follow-up on Mr. Wenstrup's statements and the
difference between staffing and productivity of a physician. It
seems like everything he said made complete sense to me, so, I
wanted to ask the IG if you could make any comments relative to
this notion of really separating sort of staffing needs, vis-a-
vis, physician needs and that measurement so that the physician
can see more patients in a given day, rather than less, vis-a-
vis, the private sector.
Ms. Halliday. That is a good question.
From our perspective, VHA is going to need to make a major
investment in collecting this information to actually measure
productivity. They are going to need to define their business
rules, and in defining their business rules, they are also
going to need to identify those activities that vary from
medical facilities so they can do comparability studies and
look at efficiency over time.
I think if they do a good job of identifying their business
rules, they will get meaningful data to which they can make
well and informed decisions. That is the basis because it is so
expensive to collect this type of information and we want it to
have a very high value and utility, so it can be used to make
the system better.
I look at the report we did here as looking at the first
part of the patients entering the system, and I understand Dr.
Agarwal's looking at, the quality of care, but I see that as
the second part. And I would like the VHA to focus on this,
because I do think that one of the biggest challenges in VA are
waiting times, and, as the Chairman said, the inconsistencies
in the quality of care of the services provided.
Ms. Brownley. Thank you. Do I have enough time for one more
follow-up question?
Mr. Benishek. Yes, please.
Ms. Brownley. My last question would be if we don't have a
system in place now----and, obviously, the demand is going to
be higher over the next three years. So my question is: Without
a measurement, without a plan, how are you anticipating
planning staffing levels currently?
What are we doing in year one, two, and three before you
have completed all of this?
Ms. Agarwal. Thank you, madam. That is a very good
question, and I will ask our operations network director.
Dr. Murawsky. Thank you, ma'am. Currently, the productivity
data is available to all of our facility chiefs of staff, other
selected members for individual level data across the system,
and any physician within VHA can access the productivity data
by practice, currently. So, that data is available for making
decisions, which we then add on to data, as you are suggesting.
What does our market penetration look like in terms of
veterans using us? What do we expect in those individuals
coming home for our numbers to increase? What do we see for
demand?
The primary care model, which is panel-based, is entry
point for most of our veterans. So, as we look at new
enrollees, that drives new FTE into the system for primary
care.
As primary care goes up, facilities look at that ratio of
primary to specialty care and begin to see as primary care goes
up, we know there is going to be an increase in certain kinds
of special services.
The goal of the PACT model is to bring as much of that care
in the PACT Team as possible and use the specialists for only
those things that they need to do, the things they are best
trained for, to avoid the patient having to have excess
visits--the things the patients need a specialist for. So, then
we will have a certain ratio to be able to do that work.
In the current system, we look at those pieces of
information, drives of the demand, access data, to make
decisions on adding new providers.
Ms. Brownley. So, for 2013, do you know exactly what you
are looking at in terms of what your needs are for staffing?
Dr. Murawsky. I can only speak from the facilities that are
within my network, that we look at our market penetration
ratio, and what we are hearing from the Department of Defense,
as what is coming home, and we try to adjust our staffing
numbers for the next year to look at the FTE levels as a whole,
that we can support with the budget we have.
Ms. Brownley. Thank you. I yield my time.
Thank you, Mr. Chair.
Mr. Benishek. The doctor, from Ohio?
Mr. Wenstrup. Yes, thank you. In my previous job before
coming here, one of the things that I was part owner of a
surgery center. At one point we sold it to the hospital. What
you are seeing in situations like that, and within hospitals,
is physician management, the direct-physician involvement, and
I appreciate you being involved, Doctor, but this involves all
the doctors that are on this staff, as far as managing the
center.
So, although we were no longer owners of the center or the
hospital, we were directly involved in how it was managed, and
we were incentivized, of course, by increased productivity. We
were incentivized to decrease the cost-per-patient ratio, and
we were always incentivized to have assured quality, as far as
patient care. Now, this seems to work pretty well in a civilian
environment.
And do you think there is any prospect or has there been
any discussion along those lines of direct-physician
involvement? I don't mean outside physicians, but the
physicians that work at the VA, where they are somewhat
incentivized to develop plans for the VA hospital, to be in a
situation like that. Did you do--increase productivity, reduce
costs, and assure quality?
Ms. Agarwal. Certainly, sir. From the headquarters level, I
know that--which is where I am at this point in time. I was at
the medical center about seven or eight years ago and I do
recall sitting with the chief of staff and having these very
discussions at that time.
And at the central office level, there is certainly a bit
of a difference in what sorts of discussions take place.
I am going to, again, rely on my network colleague to help
address what they are doing at both the network level, because
they are allocated a certain amount of money, and then--which
goes down to different facilities--as to how at the more
functional unit levels, are they having the participation
amongst physicians and other colleagues in the nursing and
pharmacy, all important parts of it.
And, in getting that sort of exact message across, that how
do we increase access and how do we improve quality of care?
Dr. Murawsky. Thank you. We are a physician-lead
organization, and--and my experience in moving up from the
medical centers, the physicians lead the practices and are very
engaged, both at the section chief level, even a practice
manager level, and then the individual physicians in doing
this; hence, we make the productivity by practice open and
available to all physicians. Any front-line physician can go in
and see how their practice performs.
We protect the individual information, so that this is not
an I-am-better-than-you model. We do drive our decisions, and I
think the question that you raised is exactly why some of the
early work of the task force was to develop tools for our
chiefs of staff, to provide them with information in a balance.
How does the productivity look at the practice level; what
does the access look like at the practice level; are there
surrogate measures of quality that we select out that are
important to have; and what is the cost per patient; what are
we spending on contract and fee services?
So, that when that section has their resource meetings and
then brings that to the chief of staff to go to resources, they
are looking at that information and saying, I am out of balance
or I am in balance and what I am going to do?
The complicatedness, of course, is the mixed mission of
having to balance our educational needs. Sometimes you have a
very high number of residents or students. It does lower the
overall productivity and you have to look at that and make some
determinations.
Mr. Wenstrup. Thank you. I guess where I am really driving
is, I just would like to know how much participation really
takes place from the doctors that are taking care of the
patients. I mean, all of those things that you mentioned are
very legitimate. And how much actually takes place and what is
their incentive to be driven and to be more efficient and to
increase productivity?
Dr. Murawsky. So, we have those discussions, and as a
primary care provider at the Hines Medical Center, we have team
meetings. I am part of those meetings, and we discuss how is
our panel size; what does it look like; where is it going; what
is our ratio of new patients; are we growing; what do we expect
to come in?
All of those things are discussed. My personal performance
pay arrangement with my boss incentivizes me a very small
amount--a couple hundred dollars in my case--for work around
keeping my panel optimized. And we have that discussion
individually with providers, so I had it with my boss at the VA
at Hines, who does my performance at, clinically. We had that
discussion.
In specialty care, the practices have that discussion among
the groups--what are they doing? It varies from setting to
setting. Some of our specialty-care practices are a single,
part-time individual, because that is the level of facility
that we have.
Mr. Wenstrup. Thank you. I guess I want to be somewhat
assured that each individual practitioner has some motivation
to be part of that solution in some way, shape or form, whether
it is monetary, or promotional or whatever.
But thank you, I yield back.
Mr. Benishek. The Member from California, Ms. Negrete-
McLeod, do you have any questions?
[Nonverbal response.]
Mr. Benishek. All right. Thanks. Does anyone else have any
further questions that they would like to ask?
If not, I guess we will wrap it up here. Thank you for
coming. I think we have asked some questions here to get things
started. Obviously, I think we are all disappointed by the fact
that we don't have a plan already. I am disappointed by that,
but I appreciate, Dr. Agarwal, your efforts to get this done.
I am just concerned by the fact that there seems to be a
great deal of difference between facilities and that there does
not seem to be overall guidance, towards the facilities to make
sure that there is adequate infrastructure exam rooms, nurses
etc. to make sure that the facility operates efficiently.
I think from today's testimony, we found that that occurs.
It certainly happened in my experience, and there are
circumstances where it does not occur, but the fact that we
don't have a plan to be sure that there is at least some sort
of efficiency is disappointing.
I look forward to your further testimony and I will monitor
what happens from here. I appreciate everyone's testimony today
and for your time. You all are excused, now. I ask unanimous
consent that all Members have five legislative days to revise
and extend their remarks and include extraneous material.
Without objection, so ordered.
Thank you, again, to all the witnesses and the audience
members for joining us. The hearing is now adjourned.
[Whereupon, at 11:42 a.m. the Subcommittee was adjourned.]
A P P E N D I X
----------
Prepared Statement of Hon. Dan Benishek, Chairman
Good morning. I want to begin by thanking all of those in
attendance today for joining us at the first Subcommittee on Health
oversight hearing of the 113h Congress.
I am honored to have been selected to serve as Chairman of this
important Subcommittee, and I am pleased that Julia Brownley of
California has been selected to serve as Ranking Member.
I look forward to working with her and the many new and returning
Members of the Subcommittee individually and collectively to improve
and protect the health of our honored veterans.
Having served on this Subcommittee before, I know that each of us
shares an immense respect and deep admiration for the service and
sacrifices of America's veterans.
My goal as Chairman, in part, is:
(1) to ensure that when a veteran accesses health care through VA,
he or she is met with timely, consistent, high quality care and
services and is unburdened by lengthy wait times or unnecessary travel
requirements; and,
(2) to keep the dollars we spend on VA health care close to the
bedsides of our veteran patients - that is to say, to prioritize
patient care above administrative costs and bureaucratic overhead that
serve the Department more than it serves our veterans.
I was proud to serve for twenty years as a part-time physician at
the Oscar G. Johnson VA Medical Center in my hometown of Iron Mountain,
Michigan.
In that capacity, I cared for my veteran neighbors every day and,
in the course of that care, I got to know them, to talk to them, and to
learn from them about the many challenges and frustrations they face
accessing health care through VA.
As a Congressman, I have made it a priority to continue these
conversations with my veteran constituents and I can tell you that -
unfortunately - their experiences at VA haven't changed for the better.
There are many examples I could provide - examples of veterans
seeing a different doctor every time they go to VA for an appointment
and examples of veterans from my district being told to travel hundreds
of miles from our home in Northern Michigan to the VA medical centers
in Milwaukee or Detroit because local doctors can no longer provide
needed services in our community.
I am convinced that these problems are rooted at least partly in
the issue we will discuss today - the persistent lack of staffing
standards at VA medical facilities.
On December 27, 2012, the VA Inspector General issued an audit of
physician staffing levels for specialty care services.
The IG found that VA did not have effective staffing methodology to
ensure that appropriate staff is in place to treat veteran patients at
VA medical facilities across the country.
Since 1981, no less than eight audits and reports have been issued
by either the VA Inspector General or the Government Accountability
Office that have recommended VA develop and implement productivity
standards and staffing measures to more effectively meet patient
demand.
32 years later, alarmingly little progress has been made and our
veterans are the ones who suffer for it.
That is unacceptable to those of us on this side of the dais and it
should be unacceptable to those on that side of the dais as well.
Today, I don't want to hear excuses. I want to hear solutions.
I thank you all for joining us this morning.
Prepared Statement of Hon. Julia Brownley
Mr. Chairman, I would like to thank you for holding today's
hearing.
As the new Ranking Member of the Subcommittee on Health, I look
forward to working with you, the other Members of this Subcommittee,
and all of our stakeholders to ensure quality, timely, and accessible
health care to all veterans.
We are here today to address the very important issue of physician
staffing within the Veterans Health Administration (VHA). We know that
access to health care is essential to veterans. It improves treatment
outcomes and quality of life for those who have it. And we know that
health care professionals are VHA's most important resource in
delivering high-quality care and services to our Nation's veterans.
Since 1981, there have been several reports that have recommended
that VA implement measures to assess provider productivity, staffing
levels, and associated resources. I understand that the wide range of
specialties VHA offers varies in complexity, and that it is often
difficult to quantify the work that specialists provide day in and day
out.
However, in a system with over 152 medical centers and nearly 1,400
community-based outpatient clinics, it is vital that VHA is able to
establish a staffing methodology to help evaluate productivity,
identify best practices within specialties, and develop staffing plans
in order to properly manage resources. Additionally, with recent
veterans returning from war and becoming eligible for VA services in
record numbers, VHA also needs to be looking toward the future to
ensure that patient needs can be met.
I thank all of the panelists for being here today. And I look
forward to hearing from them on how to proceed to ensure that VA
staffing levels are adequate and productivity levels are sufficient in
meeting the needs of our veterans.
Thank you, Mr. Chairman. I yield back.
Prepared Statement of Hon. Raul Ruiz
Thank you Chairman Benishek and Ranking Member Brownley for holding
today's hearing. I am looking forward to learning more about the
Department of Veterans Affairs (VA) Veterans Health Administration
(VHA) productivity standards as it relates to physicians and how it
affects veteran care.
The importance of today's hearing resonates all too well with my
past experience as an emergency room doctor. Productivity standards and
ensuring appropriate staffing levels is critical to a well-run
hospital. And the methodology that we established permitted us to not
only maintain an appropriate workforce, but also to have experienced,
trustworthy staff members who could deal with the pressures of the ER.
The importance of having this type of qualified staff on hand
cannot be underscored enough. They are by a patient's side caring for
them in some of the most vulnerable points in a person's life. They
care not only for a person's physical wellbeing, but also for their
emotional wellbeing. And they do this day in and day out because they
are providing what hospitals are truly about: high quality, patient-
centered care.
Our veterans deserve this type of care at all VA Medical Centers,
and I believe the VA is currently doing what they can to provide this
level of care. However, I believe that there is always room for
improvement and I know the VA has the capacity and the leadership to
develop appropriate procedures to measure physician productivity and
recruit and retain doctors, nurses, and pharmacists.
If an opportunity arises where I could provide the VA with my
expertise in the private sector, I would be delighted to work alongside
you to develop a methodology that strengthens the care we provide our
veterans. I hope you will consider my offer to collaborate and will
reach out to my office so that we can have a longer discussion on this
issue.
Thank you and I yield back the balance of my time.
Prepared Statement of Linda A. Halliday
INTRODUCTION
Mr. Chairman and Members of the Subcommittee, thank you for the
opportunity to discuss our report, Audit of Physician Staffing Levels
for Specialty Services, that was issued in December 2012. I am
accompanied by Mr. Larry Reinkemeyer, Director of the Office of
Inspector General (OIG) Kansas City Audit Operations Division, who
directed the team conducting this audit.
BACKGROUND
The need for the Veterans Health Administration (VHA) to develop a
staffing methodology is not a recent issue. In 1981, the Government
Accountability Office (GAO) recommended that VHA develop a methodology
to measure physician productivity. Since then, six OIG and GAO reports
have made similar recommendations. \1\
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\1\ Audit of VHA Resource Allocation Issues: Physician Staffing
Levels (1995); Audit of VHA's Part-Time Physician Time and Attendance
(2003); Issues at VA Medical Center Bay Pines, Florida, and Procurement
and Deployment of the Core Financial and Logistics System (2004);
Review of Selected Financial and Administrative Operations at VISN 1
Medical Facilities (2006); Follow-up Evaluation of Clinical and
Administrative Issues Bay Pines Health Care System, Bay Pines, Florida
(2006).
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In January 2002, Public Law 107-135, Department of Veterans Affairs
Health Care Programs Enhancement Act of 2001, mandated that VA
establish a nationwide policy to ensure medical facilities have
adequate staff to provide appropriate, high-quality care and services.
Specifically, VA medical facilities should consider staffing levels and
a mixture of staffing skills required for the range of care and
services provided to veterans. Organizations also need to establish
performance measures to make comparisons and assessments of different
data to be able to take appropriate action.
In a memorandum dated January 25, 2005, the Deputy Under Secretary
for Health for Operations and Management directed VHA to continue the
development of a productivity-based model for specialty care services
using the Relative Value Unit (RVU) measure. An RVU is a value assigned
to a service (such as a medical procedure) that establishes work
relative to the value assigned to another service. For example, a
service with an RVU of ``2,'' counts for twice as much physician work
as a service with an RVU of ``1.'' It is determined by assigning weight
to factors such as the:
Time required to perform the service
Technical skill and physical effort
Mental effort and judgment
Psychological stress associated with the service and risk
to patient
In 2006, VHA's Office of Productivity, Efficiency, and Staffing
conducted studies of 14 specialty care services, which resulted in 9
recommendations. One of the nine was to have VHA develop RVU
productivity standards and staffing guidance for the field.
AUDIT OF VHA'S PHYICIAN STAFFING LEVELS FOR SPECIALITY CARE
In order to evaluate VHA's progress in implementing the policy on
the physician staffing levels, we assessed whether VHA had an effective
methodology for determining physician staffing levels for 33 of VHA's
specialty care services. Generally, we found that while there is a
consensus among VHA officials that VHA needs to develop a methodology
to measure productivity, there is no agreement on how to accomplish it.
There is a lack of agreement within VHA on which methodology to use to
measure productivity. Some VHA officials believed the RVU-based
productivity model is not a good measure as a stand-alone component for
staffing, while other VHA senior officials from the Office of Patient
Care Services and medical facility officials stated that based on data
availability, the RVU model is the best method currently available to
measure productivity.
We were told VHA officials were concerned that its National Patient
Care Database did not capture all of the physician workload needed for
use in productivity-based staffing models. For example, VHA officials
explained that physicians who supervise residents accomplish less
workload than their peers who do not supervise residents because the
residents will get credit for the work completed. While this may be
valid if VHA is trying to establish individual physician productivity,
it is not a valid concern when developing a productivity standard for a
specific specialty within similar medical facilities. Further, VHA can
adjust the productivity standard for physicians whose other duties,
such as resident supervision, results in the physician accomplishing
less workload then their peers.
If VHA decides not to use RVUs as the productivity standard, VHA
can explore other options, such as panel size or other types of
productivity-based workload measures. Panel size, which is used in
primary care services, is the maximum number of active patients under
the care of a specific provider. VHA currently collects data, such as
the number of encounters and unique patients, which they could use to
develop a productivity-based methodology. While we do not endorse any
one specific method to measure physician productivity, we do believe
that VA needs to have measurable and comparable productivity standards
in place to assist in determining the number of specialty physicians
needed to meet patient care needs. Our concern is that VHA's decision-
process to implement productivity standards has been pending too long.
Productivity of VHA Specialty Physicians
In the absence of a productivity standard, we established a
rudimentary, conservative standard by identifying VHA's RVU median for
each specialty care service to determine an approximate measure of
current physician specialty productivity. The national median is the
middle value among each specialty care service. Using that median, we
analyzed the collective group of specialty physicians at all medical
facilities and determined that 12 percent (824 of 7,011) of physician
full-time equivalents (FTEs) did not perform to the standard. The 824
physician FTEs represented approximately $221 million in physician
salaries during fiscal year 2011. Although we did not analyze the
productivity of individual physicians, our results support the need for
an in-depth evaluation of staffing.
Opportunities to Identify Best Practices
VHA does not have an internal measure to benchmark physician
productivity within a specialty. GAO's Standards for Internal Control
in the Federal Government \2\ requires an organization to compare
actual performance to results and analyze significant differences
within that organization. We compared the staffing levels to the amount
of work performed by eight specialty care services \3\ at the five
medical facilities \4\ we visited. Specifically, we compared the
workload output per clinical FTE for each specialty care service and
found significant differences in workload.
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\2\ The Federal Managers' Financial Integrity Act of 1982 requires
GAO to issue standards for internal control in Government. The
standards provide the overall framework for establishing and
maintaining internal control and for identifying and addressing major
performance and management challenges and areas at greatest risk of
fraud, waste, abuse, and mismanagement.
\3\ We reviewed the following specialty care services: cardiology,
endocrinology, infectious disease, obstetrics and gynecology,
ophthalmology, physical medicine and rehabilitation, psychiatry, and
surgery.
\4\ VA Medical Centers in Augusta, GA; Boston, MA; Houston, TX;
Indianapolis, IN; and Philadelphia, PA.
One medical facility classified as ``1a'' by the Facility
Complexity Level Model had 1 FTE providing infectious disease care to
316 unique patients for a total of 603 encounters. \5\ During the same
period, another medical facility also classified as ``1a'' had 1.4 FTE
that provided infectious disease care to 1,868 unique patients for a
total of 3,476 encounters. The latter medical facility provided over
500 percent more encounters with .4 FTE or 40 percent more in staff.
---------------------------------------------------------------------------
\5\ The Facility Complexity Model classifies VA medical facilities
at levels 1a, 1b, 1c, 2, or 3. Level-1a facilities are the most complex
and level-3 facilities are the least complex. VHA determines complexity
levels by three categories--patient population, clinical services
complexity, and education and research.
---------------------------------------------------------------------------
One medical facility classified as ``1a'' had .8 FTE
providing endocrinology care to 1,053 unique patients for a total of
1,627 encounters. During the same period, a medical facility also
classified as ``1a'' had .4 FTE that provided endocrinology care to
1,347 unique patients for a total of 2,286 encounters. Although the
latter medical facility had about 50 percent less dedicated FTE, the
medical facility provided 41 percent more encounters.
VHA needs to implement productivity standards to measure and
compare the collective productivity of physicians within a specialty
care service at similar VA medical facilities. By measuring and
comparing internal productivity and staffing, VHA can identify staffing
shortages and excesses along with best practices and those practices
that should be changed or eliminated.
Staffing Plans Were Not Prepared
VHA policy requires medical facilities to develop staffing plans
that address performance measures, patient outcomes, and other
indicators of accessibility and quality of care. These assessments
determine if staffing levels need an adjustment--up or down--to meet
current or projected patient outcomes, clinical effectiveness, and
efficiency.
Staffing plans are an important control to ensure effective and
efficient use of funds by providing some certainty that medical
facility officials conduct periodic assessments of their staffing
needs. These plans also ensure medical facility directors have
sufficient data to make sure staffing decisions address VHA's
priority--providing quality patient care--along with their other
missions such as teaching and research.
None of the five medical facilities we visited could provide a
staffing plan that addressed the facilities' mission, structure,
workforce, recruitment, and retention issues to meet current or
projected patient outcomes, clinical effectiveness, and efficiency.
Medical facility officials stated that when requesting additional staff
or filling a vacancy, they provide a workload analysis to justify the
personnel action. However, medical facility officials could not always
provide documentation or an adequate workload analysis to justify the
need for additional staff.
For example, one medical facility provided us with the
justification used to replace a part-time surgeon. It showed the
surgeon was responsible for 13 percent of the work performed by the
specialty care service. In the justification, the requesting official
concluded the remaining two full-time surgeons would not be able to
absorb the departing surgeon's patient care responsibilities. However,
the requesting official provided no other information such as total
workload, anticipated workload increases or decreases, or an analytical
review of the other surgeons' ability to handle more workload.
This occurred because current VHA policy does not provide
sufficient detail for medical facilities to develop their staffing
plans. Officials from all five medical facilities stated they were not
sure what was required to implement a staffing plan. According to VHA
officials, the staffing policy was intentionally general in nature
because medical facility officials determine staffing levels on various
factors, such as the needs of each medical service, the number of
residents, and the types of care provided. Without detailed staffing
plans, VHA lacks assurance that medical facility officials are making
informed business decisions that best ensure efficient use of financial
resources in determining the appropriate number of specialty care
physicians.
Recommendations
We recommended the Under Secretary for Health establish
productivity standards for at least five specialty care services by the
end of FY 2013 and approve a plan that ensures all specialty care
services have productivity standards within 3 years. We also
recommended that the Under Secretary provide medical facility
management with specific guidance on development and annual review of
staffing plans.
The Under Secretary for Health agreed in principle with our finding
and recommendations. We consider the planned action acceptable and will
track progress.
CONCLUSION
Staffing for specialty care services is an expensive resource which
needs to be managed effectively. VHA has not established productivity
standards for all specialties because of indecision regarding how to
measure physician productivity. Instead of focusing on the difficulties
of measuring productivity, VHA needs to focus on the benefits of
discovering medical facilities that might have a best practice and
identify practices that should be changed or eliminated. This would
maximize the use of physician resources while increasing access and
quality of care to more veterans.
Mr. Chairman, this concludes my statement. We would be pleased to
answer any questions that you or other Members of the Subcommittee may
have.
Prepared Statement of Larry H. Conway, B.S., R.R.T.
Mr. Chairman and distinguished members of the Subcommittee:
I am Larry H. Conway and I am the Director of Communications for
the National Association of Veterans' Affairs Physicians and Dentists
(NAVAPD) and I am honored to have this opportunity to represent NAVAPD
in that role before the Subcommittee. I also currently serve as the
Chief of the Respiratory Therapy Subsection at the Washington DC VA
Medical Center, and for 38 years have practiced as a respiratory
therapist in various hospitals, primarily in management roles. In these
roles, I have become extremely familiar with using and developing
various methodologies of assessing healthcare staffing needs and
productivity systems. NAVAPD President Dr. Samuel Spagnolo regrets
being unable to participate today but has asked me to present NAVAPD's
concerns and thoughts on developing a methodology for determining VA's
physician staffing needs, and the VA's ability to adequately meet
patient needs in an efficient, effective manner.
NAVAPD's focus since its inception in 1975 has been promoting and
supporting the highest quality care for our Nation's Veterans, and
caring for those who provide care for them. To that end, NAVAPD
supports the development of a balanced, fair and appropriately
administered staffing and productivity system that will help assure
appropriate staffing levels to provide the excellent care due our
Veterans without undue or inequitable stress upon the caregivers. The
absence of such a VA-wide system, and the flaws in the systems
currently in use in some facilities, have led to productivity
assessment approaches that are neither fair nor balanced, and in fact
misleading and useless in determining staffing needs and performance
levels.
We became aware of concerns about these issues over the last two
years through comments from our members. We reviewed the OIG Audit of
Physician Staffing Levels for Specialty Care Services (December 27,
2012) and found that it confirmed many of the issues that had been
brought to us. The processes being used, where and when used, are
fundamentally flawed, based upon the wrong measurement units, and in
some cases favored certain staff members while harming or diminishing
others. The system can make a physician who performs procedures
continually for their entire shift appear less ``productive'' than a
fellow physician who performs procedures only a few hours out the
shift. Whether this is because of a lack of understanding of the
fundamentals of a staffing and productivity system or intentional,
cannot be firmly ascertained. Regardless, these concerns and review of
the OIG Audit culminated in an article in the current NAVAPD
Newsletter. This article was written and planned for publication before
NAVAPD became aware of this hearing and details many of the experiences
of NAVAPD members and the parallel findings by the OIG.
Developing such a system for the VA is a challenge, but it is not
nearly impossible and should not take a decade to accomplish. In my
management roles across the United States, I have devised, reviewed,
developed and refined multiple staffing and productivity systems.
Developing a system is not complex, though it can be tedious. One
barrier to progress is the assumption of an excessive degree of
complexity. Beyond selecting the correct measurement units, the
greatest difficulty will be in gaining consensus on the application of
those measurement units and the assignment of measurement units to
various procedures. NAVAPD assigns no blame to the VA for these
difficulties and does not seek to engage in controversy or
confrontation with the VA. Rather, NAVAPD would like to offer its
thoughts to the Subcommittee regarding the misjudgments in developing a
system, and further to offer assistance and expertise on how to
actualize a viable, beneficial and transparent system well within the
time frames recommended in the OIG Audit.
The Fundamental Problems
There are three issues at the heart of the current gridlock of
defining and operating a valid system for the VA:
1. Misunderstanding or misconstruction of the basic unit of
measurement, the Relative Value Unit (RVU); inclusion of extraneous
factors in the RVU.
2. Adding skill-set, procedure difficulty, and stress factors to
the RVU. This is a matter of skill-mix, which differs from basic
staffing levels
3. Confusing and mixing staffing needs assessment, productivity
assessment, and benchmarking.
RVU Selection, Definition, and Construction:
The OIG Audit stated:
``An RVU is a value assigned to a service (such as a medical
procedure) that establishes work relative to the value assigned to
another service. For example, a service with an RVU of ``2'' accounts
for twice as much physician work as a service with an RVU of ``1.'' It
is determined by assigning weight to factors such as the:
Time required to perform the service
Technical skill and physical effort
Mental effort and judgment
Psychological stress associated with the service and risk
to patient''
With respect, this is precisely the wrong approach and is at the
heart of the confusion and disarray of the current system. When asking
how many staff members are needed to effectively and safely perform a
projected workload, it is an issue of time, not difficulty or skill or
physical effort or difficulty or stress. For one thing, a more
difficult, more stressful, more skilled procedure will by its nature
take longer than a simple procedure
For purposes of determining the total number of staff hours
(staffing) needed to accomplish a given workload, the RVU should be a
simple, one-dimensional (single-factor) time-based unit. The RVU can be
defined as any convenient standard block of time, i.e., one (1) minute,
fifteen (15) minutes, one (1) hour, or any block of time that
conveniently fits the overall duration of procedures. The VA could and
should certainly set a system-wide RVU of perhaps thirty (30) minutes.
This will make the data from different services, facilities, and VISNs
easy to assimilate, aggregate, and compare without the need for
translation of base units.
Unfortunately, the RVUs being used unevenly throughout the VA
include all of those factors described in the OIG Audit. They are
similar to the Medicare-derived Resource Based Relative Value Units
(RBRV). While similarly named, RBRVs and RVUs are not the same and not
interchangeable. The RBRV is used to determine the dollar value
(reimbursement) of various procedures, and thus includes all of the
non-time factors identified above.
Figure 1
Contrast of Hypothetical RVUs and RBRVs--
----------------------------------------------------------------------------------------------------------------
----------------------------------------------------------------------------------------------------------------
1/2 hour of suturing in ED 1/2 hour of neurosurgery
a. Time = 30 minutes a. Time = 30 minutes
b. Skill factor = 1 b. Skill factor = 7
c. Difficulty factor = 1 c. Difficulty factor = 5
RVU (a) = 30 minutes RVU (a) = 30 minutes
RBRV (a x b x c) = 30 minutes RBRV (a x b x c) = 1,050 minutes
A quick review of this example reveals that the total dollar value of the same time interval of neurosurgery
would justify much more reimbursement than an equal time period of ED suturing based, upon the weighted RBRV.
However, the amount of staff time required is the same for each, based upon the RVU............................
----------------------------------------------------------------------------------------------------------------
For a measurement unit intended to determine the dollar value for a
given procedure, as the Medicare RBRV is, inclusion of all of these
factors is valid. The impact of inclusion of these non-time factors is
illustrated in Figure 1, above.
However, a measurement unit intended to determine just the number
of needed staffing hours (which translates to FTEs) should consider
only the time for appropriate and safe completion of the projected
workload. One-half hour of neurosurgery and one-half hour of wound
suturing in the Emergency Department do not require the same skill-
level and are not equally difficult. They are thus assigned differing
dollar values. But they both take one-half hour of staff time, which is
the question when determining how many staff members are needed to
complete a whole mix of various procedures.
The question of how many of each type of staff is needed (skill-
mix) can be addressed in one of two ways, as described in the next
section, but must not be mixed into the RVU.
Assessment of Skill-Mix Need:
As used in these comments, skill-mix means how many staff of
various levels of skill is needed. Obviously, a hospital cannot
function with only one skill-level or specialty of physician. Having
calculated how many total minutes or hours (which can all translate to
FTEs) of personnel are needed for all procedures, how does one
determine how many Family Practice, Emergency Care, Neurosurgeons,
Cardiologists, etc. are needed within that total staffing complement?
The simplest way is to continue to use the RVU as defined
previously, but segregate the types of procedures by specialty or
skill-level. Thus, the procedures (and associated RVUs) done by
Neurosurgeons will be totaled for Neurosurgeons. Those for
Cardiologists will be totaled for Cardiologists, and so forth. This
process will produce subsets of RVUs for each specialty/skill-level,
which will define how many of each specialty/skill-level is required
for the projected workload. All of the subsets added together will
provide the total staffing complement. This concept is illustrated
below in Figure 2.
Figure 2
Determining Skill-Mix and Total FTE Needs Using Simple RVUs--
----------------------------------------------------------------------------------------------------------------
Specialty RVUs Hours FTEs
----------------------------------------------------------------------------------------------------------------
ER Physicians: 12,274 6,187 3.92
Cardiologists: 21,596 10,798 6.85
Primary Care 48,221 24,111 15.29
Intensivists 32,545 16,273 10.32
TOTAL Physician FTEs needed 36.38
-- In this hypothetical facility there are four kinds of physicians.............................................
-- An RVU is defined as 30 minutes (0.5 hours), therefore Hours = RVUs x 0.5....................................
-- An FTE is paid 2080 hours annually, but with Vacation (80), Holiday (88), Report (120), and Sick (40) time
removed, averages 1752 available work hours per year...........................................................
-- At 90% productivity, it will take 3.92 FTEs to provide the 12,274 RVUs by ER Physicians......................
----------------------------------------------------------------------------------------------------------------
Alternatively, the skill-mix need can also be calculated by using
the RBRV or another unit that considers the factors listed in the OIG
report. However, this requires an additional set of calculations and a
conversion process between RBRVs and FTEs. There is no significant
benefit in this additional, parallel system. Therefore, for the purpose
of determining total FTE need and skill-mix need, a one-dimensional
time-based RVU is the appropriate tool, not a multidimensional
construct like the RBRV.
Confusing Staffing Needs Assessment, Productivity Assessment, and
Benchmarking:
Assessing staffing needs and assessing staff productivity are
related but not the same, and confusing the two into one system will
degrade the effectiveness of the system for both. It will also create a
disincentive for staff to participate in either system.
A (relatively) simple means of determining total staffing need and
skill-mix has been described.
A productivity system functions in the opposite fashion from a
staffing needs system. It should compare the number of staff hours
available to the amount of work accomplished. Thus, if there were 1,000
hours of staff time available (based upon a needs assessment) but only
823 hours of work were accomplished (as calculated by RVU), the staff
would be considered to be 82.3% productive. The level of productivity
can be impacted and made difficult to accurately assess by several
factors, some of which are described below.
Factors which can vary facility to facility:
1. Number floors to be covered
2. Acuity of the patients
3. Number, speed, and reliability of elevators
4. Age and speed of equipment
5. Computer systems
6. Number and efficiency of support staff
7. Number of available exam rooms
8. Delays in obtaining a bed
9. Patients not available
10. Teaching obligations
11. Untracked responsibilities such as telephone consults, hallway
consults, prep time, documentation.
Fatigue and Delay factors must not be forgotten in determining
productivity, while they are often ignored in calculating staffing
levels. No one can function at 100% productivity continuously, either
for individual health or fatigue reasons, or for the reasons listed
above. Productivity specialists consider 5% to 7% a reasonable
estimate/allowance for Fatigue and Delay.
Non-tracked responsibilities or obligations that are not directly
related to procedures diminish productivity if not considered within
the build of the productivity system. Because hospitals tend to build
documentation systems around ``billable items,'' or easily identified
procedures, non-billable items are often not counted and thus
unavailable for consideration unless recorded manually.
The impact on productivity of resident training is a particularly
large factor that is missed in staffing and productivity systems. Even
the OIG Audit underplays the impact of teaching. It states:
``VHA officials were also concerned that its National Patient Care
Database did not capture all of the physician workload....For example,
VHA officials told us that physicians who supervise residents
accomplish less workload than their peers who do not supervise
residents because the residents will get credit for the work completed.
While this may be valid if VHA is trying to establish individual
physician productivity, it is not a valid concern when developing a
productivity standard for a specific specialty within similar medical
facilities.''
In fact, these teaching obligations and the impact upon the entire
specialty and facility are significant. Many VHA facilities have
specific contracted obligations to use and train residents. Resident
training is time-consuming and can reduce significantly an attending
physician's case output or require the physician to spend more hours
discharging the same caseload. The more conscientious the teaching, the
greater is the impact. Such obligations must be considered when setting
staffing levels, productivity factors and goals whether facility or
individual focused.
Poorly defined ``Encounters'' measure used by the VA are defined
more in terms of complexity than time, making it difficult to use
``encounters'' as a denominator to establish staffing need or
productivity. The amount of time required varies widely from one
encounter to the next, but all are counted as ``1.'' The more nebulous
the measurement unit or documentation unit in terms of time required,
the more difficult it is to truly assess staffing needs or productivity
of existing staff.
However thoroughly and well consider, a productivity system
inappropriately built upon a multifactor measurement unit, like the
RBRV discussed previously, can cause hard working and diligent
physicians to appear less productive than fellow physicians who do
fewer, heavier weighted procedures. This effect is demonstrated in
Figure 3 below, which is based upon the assumptions in Figure 1:
Figure 3
Contrast of Productivity by Hypothetical RVUs and RBRVs--
(In this example, an RVU is defined as 30 minutes)
----------------------------------------------------------------------------------------------------------------
----------------------------------------------------------------------------------------------------------------
The ED physician moves from patient to patient The neurosurgeon completes performs two cases
performing procedures that take 30 minutes continously totaling 4 hours of surgery during the course
of
during the shift: the shift:
a. Procedures done: 14 a. Procedures done: 2
b. Procedure time: 420 mins. b. Procedure time: 240 mins
c. RVUs = 14 c. RVUs = 8
d. Skill factor = 1 d. Skill factor = 7
e. Difficulty factor = 1 e. Difficulty factor = 5
RVU (a) = 14 RVU (a) =8
RBRV (a x b x c) = 14 RBRV (a x b x c) = 280In the same 8 hour shift, the ED physician spent a total of 7 hours (420 minutes) providing services while the
neurosurgeon spent 4 hours (240 minutes) providing services. The RVUs indicate the amount of staff time
required to provide the services of each (staff need). While the RVUs (required staff time) for the ED was 75%
greater than for the neurosurgery, the weighted RBRV indicates (incorrectly) that the neurosurgeon was 20 times
more productive than the ED physician..........................................................................
----------------------------------------------------------------------------------------------------------------
Given that the types of procedures done by physicians are not
necessarily their choice, but assigned, the situation can arise in
which a physician, by virtue of their assigned procedures, could never
achieve high productivity in a system that weights by skill and
difficulty factors as well as time. A radiologist who is constantly
assigned to read chest x-rays could read far more films and work far
more hours and never generate the total number of RBRVs as a
radiologist who does Brain MRIs or Radio-ablations. If RBRVs are then
assumed to equal productivity, the radiologist who is assigned largely
chest x-rays will always appear less productive, even if that is not
the case.
If productivity as determined by RBRVs is a major determinant in
performance assessment and performance pay, the radiologist who is
assigned mostly chest x-rays is at a continuous - and perhaps
intentional - disadvantage
In a medical system focused on profit, assessing the value of a
physician based upon the ``production'' billable revenue of one versus
another might make business sense. In the VA system, profitability is
not a factor and so assessing the productivity of a physician should be
based upon the time spent producing care results.
Finally, a benchmarking system compares performance on a ``select
group'' of procedures or services that are thought to be highly
representative of work associated with and in common with each of the
various participating facilities. Of major importance is noting that a
benchmark system makes no attempt to account for all procedures or work
performed. It therefore does not provide any estimate of the TOTAL work
performed in any facility. It is a comparator system and presumes that
if a facility has the best profile on the reported procedures, then
that facility performed better overall than the other participating
facilities.
Benchmark systems are often misused by trying to treat them as
productivity systems. The two are completely different and distinct.
There is no way to accurately assess true productivity (work produced
per staffing unit) unless all work and all staffing is accounted for.
By definition and practice, a benchmark system does not account for all
of either.
On page 4, the OIG Audit discusses an attempted benchmark looking
at infectious disease care and endocrinology care. The OIG
investigators then ran productivity comparisons of the two specialties
in two different ``1a'' facilities. While the results imply that one
facility was far more productive, the fact is that other procedures and
factors not in the scope of the benchmark reporting likely account for
some of the variability. This attempt at using benchmark data to derive
productivity information produced data that truly only showed that the
results were suspect because no standards of measurement and comparison
had been established. Because all factors and procedures are not
included in a benchmark system, there is little chance of deriving
generalized productivity information from it.
A benchmark system may be an effective tool for identifying best
practices only if the scope and limitations of its data pool are
recognized and considered in any conclusions.
The Greatest Barriers
The greatest barrier to the development and implementation of an
accurate Staffing Needs Assessment system and a Productivity Assessment
tool will be defining the measurement unit and applying it to all
procedures. This will require two major accomplishments:
1. A complete inventory of procedures, events, obligations that
account for sizable portions of staff time, billable or not, linked to
a procedure or not; and
2. Consensus on the application of the measurement unit to each
item in this inventory. For example, getting agreement on ``What is the
most accurate average time required to perform a Brain MRI?'' What is
the most accurate average time required to read an EKG?''
The next greatest barrier will be getting staff participation. No
one likes another person monitoring them and their work. Health care
providers are especially suspicious of such a system. They realize that
they are working with people, not building cars, and that ``cookbook''
approaches do not account for the variability of people and their
medical responses. It will therefore be important that the construction
of the system and the operation of the system is transparent to all.
Finally, developing a means of easily collecting the data will be
key to success. A process that would auto-populate a procedure tracking
and counting system will assure the most accurate reporting.
I would like to conclude by reiterating that NAVAPD recognizes the
enormity of establishing a Staffing and Productivity system for the VA,
but supports that effort, and offers its assistance in making such a
system a reality soon. Mr. Chairman, I would like to thank you and the
members of the committee for your kind attention. I would be happy to
answer any questions from you or other members of the committee.
Prepared Statement of Madhulika Agarwal, M.D., M.P.H.
Good morning, Mr. Chairman, Madam Ranking Member, and Members of
the Subcommittee. Thank you for the opportunity to discuss the
Department of Veterans Affairs' (VA) productivity levels for
physicians. I am accompanied today by Dr. Carter Mecher of the Veterans
Health Administration (VHA)'s Office of Public Health, and Dr. Jeffrey
A. Murawsky, Director of VHA's Great Lakes Health Care System.
VHA believes it is essential to ensure that all employees within
our Administration, including our physicians, are able to work as
effectively as possible to provide appropriate, high-quality care and
services and meet the needs of Veterans.
VHA currently uses both population-based (primary care physicians)
and work value-based (specialist physicians) models to assess physician
productivity, that will soon be used in over half of our physician
workforce. VHA is committed to establishing appropriate productivity
models for five additional specialties by the close of this fiscal
year. Over the next three years, we will refine and develop additional
models that are individualized for specialty care.
Measuring productivity in a health care setting is a complex issue.
First, I would like to discuss some of those complexities as they
pertain to VHA. I then will describe actions VA has already taken, and
is in the process of taking, to measure effectiveness and productivity
in achieving all of our statutory missions.
VHA has four principal missions for which it is responsible. These
include patient care, medical education, research, and support to the
Nation's emergency preparedness. In Fiscal Year 2012, eighty-four
percent of our physician full-time-equivalent (FTE) workforce was
providing direct patient care to Veterans, our primary responsibility.
VHA fully recognizes it is incumbent on us to effectively manage
this very important resource. However, we also know that VHA--and the
entire medical profession--has had a long history of challenges in this
area. These issues include changing needs of patients; changing
practice patterns, new delivery models, impact of technology
innovations on patterns of care, challenges with physician recruitment
and retention; and accurately measuring productivity in an integrated
health system.
Just last month, the Bipartisan Policy Center issued a report
entitled ``The Complexities of National Health Care Workforce
Planning,'' which described the issues facing the entire health care
industry. The complexities addressed are no different from those that
VHA faces. It is my privilege to inform this subcommittee, America's
Veterans and their families, and other interested parties of the
actions we are taking to ensure our physician workforce is optimally
deployed to provide America's Veterans with the quality of care they
have earned through their service and sacrifices.
Quality, accessibility, and efficient delivery of health care are
basic principles VHA uses to develop physician productivity and
staffing standards. To ensure this, VHA has established an Office of
Productivity, Efficiency, and Staffing (OPES) to build tools to help
program offices develop effective management strategies, systems, and
studies to optimize clinical productivity and efficiency, and to
support the establishment of staffing guidance that promotes the goals
of clinical excellence; access; and the provision of safe, efficient,
effective, and compassionate care. OPES produces a number of tools,
such as the Physician Productivity Cube, which VHA uses to monitor
productivity, staffing and efficiency.
VA has moved from a hospital-based system to a health care system
with a focus on ambulatory care. The foundation of our integrated
health care delivery system is primary care, and primary care
physicians were our first priority for developing a staffing model.
Primary care providers constitute the single largest component of our
physician workforce, 34 percent. VHA now has a fully operational
Primary Care Panel Size Staffing Model, which defines the number of
active patients that may be assigned to each primary care provider. In
developing this staffing model, our goal was to establish a primary
care system that balances productivity with quality, access, and
patient service. In addition, the staffing model permits VHA to measure
the overall productivity of primary care providers and the capacity of
our system, in order to understand and inform our primary care staffing
needs. Currently we are completing the process of updating that model
to reflect changes associated with VHA's deployment of patient-aligned
care teams (PACT) at all our sites of care.
The second largest component of our physician workforce is our
Mental Health providers. Psychiatrists now account for 14 percent of
VA's physician workforce. Mental Health has experienced unprecedented
growth in the past two years-- driven by sharply increasing demand for
Mental Health services. VHA has comprehensively studied our mental
health provider resources to ensure that they are optimally deployed
and used. We will be distributing a directive providing guidance for
facilities to support this objective, entitled ``Productivity Guidance
for Mental Health Providers,'' by the end of spring, 2013.
Relative Value Units (RVUs) are used by Medicare, Medicaid, and
many private practices and institutions, to track physician
productivity. RVUs consider the time and intensity of physician
services and have three components: (1) the Work RVU (wRVU)
encompassing time spent before, during and after the service and
considers the technical skill, physical effort, mental judgment, and
potential risk of performing a medical service; (2) the Practice
Expense (peRVU) which considers the support staff, medical supplies and
equipment needed to perform a procedure and; (3) the Malpractice
(mpRVU) which measures the liability costs associated with each medical
procedure. Each of these RVU components is determined by applying the
Centers for Medicare & Medicaid Services' weights to CPT codes (Current
Procedure Terminology) of patient encounters. Only the wRVU component
is used for physician productivity measurement.
While many private sector healthcare organizations use the
industry-accepted metric of wRVUs to determine productivity, wRVUs also
are used in academic and private practices to determine physician
compensation.
VHA intends to expand the use of wRVUs as only one of several
measures to assess the productivity and efficiency of each specialty
practice area throughout the organization.
Radiology, the third largest component of our physician workforce
(nearly 6 percent of the total workforce) offers a good example of how
wRVUs can be used to set productivity levels. A comprehensive study of
the productivity of VA radiologists was performed in Fiscal Year 2005.
The study found that the observed mean productivity of radiological
specialists was 5,453 wRVUs per physician, and the median was 4,904
wRVUs. VHA determined that radiologists assigned to full-time clinical
effort should produce 5,000 wRVUs of work in the course of a year. In
Fiscal Year 2012, the observed mean productivity per clinical full-time
equivalent radiology physician increased to 5,652 wRVUs. This
productivity standard is assessed on an annual basis.
To assist local leadership in managing their specialty practices,
information is available on the VA Intranet that provides data on
productivity and includes factors that affect productivity, such as the
presence and number of support staff. Utilizing the metric of a wRVU
permits measurement of cost efficiency and the ability to study the
relationship of productivity, efficiency and outcomes.
When the Mental Health directive is published, more than 54 percent
of VHA's physician workforce will have standards to measure their
productivity and efficiency. OPES has created a tool called the
Physician Productivity Cube, a tool that captures physician
productivity workload for physician specialties by measuring workload
by wRVUs, number of encounters, and number of individual patients. It
also gives our hospitals and health care systems the capability to
assess their productivity and to compare themselves to national
medians, medical centers of similar size and complexity, and private
sector benchmarks. It is a quarterly reporting system of our physician
workforce. However, given the inherent complexity of this effort, OPES
is doing extensive validation of the local primary data contained in
the cube's database.
The Office of Inspector General (OIG) was given access to the
Physician Productivity Cube, and noted significant variation in
observed productivity within VHA and recommended that VHA establish
productivity standards. VHA has accepted this recommendation. Our work
in specifically addressing the problems identified by OIG began six
months before the OIG's report was released.
In June 2012, VHA established a Specialty Care Physician
Productivity and Staffing Plan Task Force to further refine our
methodology for specialty care physician productivity and staffing.
VHA's task force focused on seven specialties excluding Primary Care,
Mental Health, and Radiology, specialties for which models have already
been developed or are near release. The seven specialties were
Cardiology, Gastroenterology, Dermatology, Neurology, Orthopedics,
Urology, and Ophthalmology, which account for a major portion of our
remaining physician workforce, and are representative of all remaining
specialties. The task force's recommendation was for an RVU-based
approach that builds upon the extensive work OPES has already done in
this area.
These specialty areas comprise smaller numbers of clinicians than
Primary Care, Mental Health, or Radiology. The specialty services,
however, are typically more heavily dependent upon the availability of
capital infrastructure such as access to operating rooms and cardiac
catheterization labs; and are more heavily involved in our research
mission. The task force has initiated a pilot study in four Veterans
Integrated Service Networks (VISN) to gain insight into unique facility
characteristics that may affect physician productivity and thereby
explain some of the observed variation. For example, surgeons with
ready access to Operating Rooms (OR) will likely have higher
productivity than those clinicians in an office-based or clinic
practice. Moreover, working in operating rooms with efficient
scheduling of surgical procedures, expedient room turnover, and
adequate OR staff (nursing, anesthesiology) would be expected to impact
surgical productivity. Understanding the influence of these local
factors, such as adequate support staff ratios for our providers, is an
important component of this VISN pilot project.
In addition, OPES is testing and refining new, enterprise-wide
solutions for capturing workload that does not impose additional burden
on clinicians who are treating Veterans. We believe the results of
these pilot programs will provide the essential data needed to
establish productivity standards in these specialty areas. VHA will
make every effort to account for the unique characteristics of the
local facilities in which our specialists practice.
VA is integrating physician productivity data and measures of
access to care into a model to guide staffing decisions in specialty
care. This approach coupled with measures of quality and the amount of
specialty contract care, or non-VA community care, will help VA medical
center leaders make informed decisions on the appropriate numbers of
specialty physicians to meet patient care needs.
VHA's primary goal is improving the health and well-being of our
Veterans. We are reorienting to deliver more proactive, personalized
and patient-driven care. In addition to our commitment to establish
productivity standards for five specialties by the end of this fiscal
year, excluding, Primary Care, Radiology and mental health, we will
ensure a plan is in place to establish productivity standards for all
specialty care services within three years. We will provide specific
training to the leadership of all our health care facilities on how to
utilize the data from the Physician Productivity Cube. We will provide
medical facility directors more specific guidance on how to develop
staffing plans and ensure medical facility management reviews them
annually to ensure optimal efficiency.
In the process of introducing these changes, VHA will ensure that
Veterans continue to have access to the highest quality primary and
specialty care.
Mr. Chairman, this concludes my testimony. We appreciate the
opportunity to appear before you today to discuss this important issue.
My colleagues and I are prepared to answer your questions.
Materials Submitted For The Record
Congressional Hearing Deliverables
Date: March 13, 2013
Source: Hearing before the House Committee on Veterans' Affairs,
Subcommittee on Health, ``Meeting Patient Care Needs: Measuring the
Value of VA Physician Staffing Standards'' (Physician Productivity
Standards)
Question from: Congresswoman Julia Brownley, Ranking Member
Provide Plan for Completion of Productivity Standards for
Specialty Physicians.
Response:
The Veterans Health Administration (VHA) will establish
productivity standards for five specialties in fiscal year (FY) 2013
and the remaining specialties by October 2015 (end of FY 2015). To this
end, the Specialty Physician Productivity and Staffing Task Force (Task
Force) will leverage the extensive work VHA has already completed in
building the necessary data sources to measure specialty physician
productivity and staffing in an ongoing and systematic way.
The primary data source that will be used to assess Specialty
Physician Productivity and Staffing in VHA will be the Physician
Productivity Cube (PPC). PPC is an analytical tool that uses ProClarity
Analytics software and provides users the ability to gain business
insight and to investigate changing provider productivity performance
and staffing levels. PPC is a critical component to VHA's ability to
systematically assess Specialty Physician Productivity and Staffing
within VHA and, as such, will continue to be refined and improved upon.
The Task Force has and will continue to validate and make
recommendations for improvement in this key data source, as well as
develop additional tools for local leadership to improve their
specialty practices with the ultimate goal of providing high quality,
efficient specialty care to our Veteran patients.
To link productivity measurement to staffing standards, the Task
Force developed a model that integrates specialty physician
productivity data and measures of access to specialty care into an
algorithm to guide staffing decisions of specialty care physicians.
This integrated approach, coupled with measures of quality and the
amount of specialty non-VA community care (Fee-Basis care), was
proposed to help VA medical center leaders make informed decisions on
the appropriate numbers of specialty physicians to meet patient care
needs. Productivity data coupled with access measures provides a
framework for determining specialty physician staffing. This model was
prototyped for the seven specialties of Cardiology, Gastroenterology,
Dermatology, Neurology, Orthopedics, Urology, and Ophthalmology.
Through the use of Veterans Integrated Service Network (VISN)
pilots, exstensive stakeholder input will be obtained and considered.
VISN pilots (VISN 7, 12, 19 and 22) have been targeted to ensure an
appropriate spectrum of U.S. regions (East, Midwest, and West as well
as a mix of rural and urban) and practice settings (Medical Center
Complexity Group (MCG) Levels) is included, as well as to ensure a core
group of VISNs to assist in the diffusion of core competencies in
specialty practice management knowledge. The VISN pilots will simulate
implementation of productivity standards
(25th and 50th percentiles by specialty and MCG) and, through this,
identify business rule gaps and any potential unintended consequences
to the efficient delivery of specialty care services to our Veterans.
Based on this feedback we will then move forward with the necessary
modifications to foundational business rule's and deploy productivity
and staffing standards for five specialties to be completed by
September 30, 2013.
VHA established four VISN pilots (VISNs 7, 12, 19, and 22) to
simulate implementation of productivity standards for five specialties.
These four VISNs were selected because they cover a broad geographic
area and cross a number of different practice settings. Productivity
standards were established based on 25th percentile and mean for each
specialty. VISN pilots focused on reviewing the accuracy of the
productivity data, identifying and addressing business rule gaps, and
potential unintended consequences to the efficient delivery of
specialty care services to our Veterans. Based on this feedback we will
then move forward with the necessary modifications to foundational
business rules and deploy productivity and staffing standards for five
specialties to be completed by September 30, 2013.
Establishment and implementation of RVU-based productivity
standards for the remaining medical and surgical specialties, is
anticipated to proceed more rapidly once this foundational work is
completed for the first five specialties.
There are three hospital-based specialty areas, Emergency Medicine,
Anesthesiology, and Laboratory and Pathology that will require a
slightly different approach to physician staffing. Emergency Medicine
staffing must be adequate to ensure 24/7 coverage for VA Emergency
Departments and Urgent Care Centers. Anesthesiology staffing must be
adequate to ensure safe staffing for all operating rooms. Laboratory
and Pathology staffing must ensure safe staffing for VA laboratories,
pathology, and blood banks. VHA has established individual working
groups for each of these specialties to develop alternatives to RVU-
based productivity models.
The following summary of VHA's operational plan details the actions
planned and in process to accomplish implementation of productivity
standards for Specialty Physicians:
Stage I: Four VISN Pilots focusing on seven specialties. Target
date for completion: July, 2013
Office of Productivity, Efficiency and Staffing (OPES)
establish preliminary productivity standards (25th and 50th percentile
for Medical Center Complexity Group (MCG) Level) for the Specialties
of: Cardiology, Gastroenterology, Neurology, Dermatology,
Ophthalmology, Urology and Orthopedics in VISN Pilots.
Status: Completed for all seven specialties and all MCG levels.
OPES develop and refine specialty practice management
tools (Quadrant Report) and Specialty Physician Workforce Reports that
integrate productivity and access measures for Medical Center
leadership to critically assess specialty physician staffing and make
informed decisions on the appropriate numbers of specialty physicians
to meet patient care needs.
Status: Quadrant tool developed for all seven specialties.
OPES develop methodology for capturing professional
services associated with inpatient care for medical specialties.
Status: Methodology developed and workload estimated for all
medical specialties.
OPES provide preliminary productivity standards for the
seven specialties for all VISN Pilot sites and identify outliers
falling below 25th and 50th percentiles.
Status: Completed.
VISN Pilots simulate productivity standard implementation
and review factors associated with productivity outliers such as
inconsistent application of foundational business rules (person class
designation, labor deployment, and professional workload capture) and
modify business rules accordingly. See Appendix A.
Status: In process. Target date for completion: June 2013.
VISN Pilots review OPES methodology for capturing
professional services associated with inpatient care for accuracy and
inclusion in productivity assessment.
Status: In process. Target date for completion: July 2013.
VISN Pilots review other factors contributing to
productivity including practice setting, support staff, specialty
demand, contract and FEE Basis care, and coding accuracy.
Status: In process. Target date for completion: July 2013.
VISN Pilots review and refine specialty management tools
(Quadrant Report) and algorithms for assessing specialty physician
staffing.
Status: In process. Target date for completion: July 2013.
Communicate and establish core competencies within
Medical Centers on effective specialty practice management inclusive of
use of tools (Physician Productivity Cube, VHA Specialty Physician
Benchmarking Report and Specialty Physician Workforce Reports).
Status: In process. Target date for completion: July 2013.
Stage II: Establish productivity standards for five specialties
across VHA. Target date for completion: October 2013.
Modify and finalize the preliminary productivity
standards for at least five of the seven specialties.
Target date for completion: July 2013.
VISN Pilots communicate and establish core competencies
across all VISNs on effective specialty practice management inclusive
of use of tools (Physician Productivity Cube, VHA Specialty Physician
Benchmarking Report and Specialty Physician Workforce Reports).
Target date for completion: August 2013.
All VISNs communicate and establish core competencies
across all Medical Centers on effective specialty practice management
inclusive of use of tools (Physician Productivity Cube, VHA Specialty
Physician Benchmarking Report and Specialty Physician Workforce
Reports).
Target date for completion: September 2013.
Health Information Management Service (HIMS) and
Compliance and Business Integrity establish procedures to ensure
accurate coding for the five specialties.
Target date for completion: October 2013.
Incorporate specialty practice management tools (Quadrant
Report) and Specialty Physician Workforce Reports into specialty
physician staffing assessments for five specialties.
Target date for completion: October 2013.
Revise VHA Policy Directives and Specialty Handbooks to
reflect the establishment of productivity standards in these five
specialties.
Status: In process. Target date for completion: October 2013.
Stage III A: Establish productivity standards and staffing plans
for the three hospital-based specialties: Anesthesiology, Laboratory
and Pathology Medicine and Emergency Medicine that require core
staffing levels. Target date for completion: October 2015.
Establish VA sub-groups to address the three hospital-
based specialties: Anesthesiology, Laboratory and Pathology Medicine
and Emergency Medicine that require core staffing levels.
Status: Establishment of these subgroups, May 2013.
Establish preliminary productivity standards and staffing
plans for these three hospital-based specialties.
Target date for completion: October 2014.
VISNs evaluate and refine preliminary productivity
standards and staffing plans and communicate and establish core
competencies across all VISNs on effective specialty practice
management for these three hospital-based specialties.
Target date for completion: January 2015.
Modify and finalize the preliminary productivity
standards and staffing plans for these three hospital-based
specialties.
Target date for completion: July 2015.
Establish and implement productivity standards for these
three hospital-based specialties.
Target date for completion: October 2015.
Revise VHA Policy Directives and Specialty Handbooks to
reflect the establishment of productivity standards in these three
specialties.
Target date for completion: October 2015.
Stage III B: Implement RVU-based Productivity Standards for the 22
remaining specialties (Table 1). Target date for completion: Half the
remaining specialties (second-tier) implemented by October 2014; and
half the remaining specialties (third-tier) implemented by October
2015.
Prioritize and identify second-tier of specialties.
Target date for completion: July 2013.
OPES establish preliminary productivity standards (25th
and 50th percentile for Medical Center Complexity Group (MCG) Level)
for the 11 second-tier specialties.
Target date for completion: October, 2013.
OPES provide preliminary productivity standards for the
11 second-tier specialties for all VISNs and identify outliers falling
below 25th and 50th percentiles.
Target date for completion: October 2013.
OPES refine specialty practice management tools (Quadrant
Report) and Specialty Physician Workforce Reports that integrate
productivity and access measures for Medical Center leadership to
critically assess specialty physician staffing and make informed
decisions on the appropriate numbers of specialty physicians to meet
patient care needs to encompass 11 second-tier specialties.
Target date for completion: December 2013.
VISNs simulate productivity standard implementation and
review factors associated with productivity outliers, such as
inconsistent application of foundational business rules (person class
designation, labor deployment, and professional workload capture), and
modify business rules accordingly.
Target date for completion: January 2014.
All VISNs evaluate and refine preliminary productivity
standards and communicate and establish core competencies across all
Medical Centers on effective specialty practice management inclusive of
use of tools (Physician Productivity Cube, VHA Specialty Physician
Benchmarking Report and Specialty Physician Workforce Reports) for the
11 second-tier specialties.
Target date for completion: March 2014.
Modify and finalize the preliminary productivity
standards and staffing algorithms for the 11 second-tier specialties.
Target date for completion: July 2014.
Establish and implement productivity standards for the 11
second-tier specialties.
Target date for completion: October 2014.
Revise VHA Policy Directives and Specialty Handbooks to
reflect the establishment of productivity standards in the 11 second-
tier specialties.
Target date for completion: October 2014.
HIMS establish Compliance and Business Integrity
procedures to ensure accurate coding for the 11 second-tier specialties
implementing RVU-based productivity standards.
Target date for completion: October 2014.
Incorporate specialty practice management tools (Quadrant
Report) and Specialty Physician Workforce Reports into specialty
physician staffing assessments for the 11 second-tier specialties.
Target date for completion: October 2014.
OPES establish preliminary productivity standards (25th
and 50th percentile for Medical Center Complexity Group (MCG) Level)
for the 11 third-tier specialties
Target date for completion: October 2014.
OPES provide preliminary productivity standards for the
11 third-tier specialties for all VISNs and identify outliers falling
below 25th and 50th percentiles.
Target date for completion: October 2014.
OPES refine specialty practice management tools (Quadrant
Report) and Specialty Physician Workforce Reports that integrate
productivity and access measures for Medical Center leadership to
critically assess specialty physician staffing and make informed
decisions on the appropriate numbers of specialty physicians to meet
patient care needs to encompass 11 third-tier specialties.
Target date for completion: December 2014.
VISNs simulate productivity standard implementation and
review factors associated with productivity outliers such as
inconsistent application of foundational business rules (person class
designation, labor deployment, and professional workload capture) and
modify business rules accordingly.
Target date for completion: January 2015.
All VISNs evaluate and refine preliminary productivity
standards and communicate and establish core competencies across all
Medical Centers on effective specialty practice management inclusive of
use of tools (Physician Productivity Cube, VHA Specialty Physician
Benchmarking Report and Specialty Physician Workforce Reports) for the
11 third-tier specialties.
Target date for completion: March 2015.
Modify and finalize the preliminary productivity
standards and staffing algorithms for the 11 third-tier specialties.
Target date for completion: July 2015.
Establish and implement productivity standards for the 11
third-tier specialties.
Target date for completion: October 2015.
Revise VHA Policy Directives and Specialty Handbooks to
reflect the establishment of productivity standards in the 11 third-
tier specialties.
Target date for completion: October 2015.
HIMS and Compliance and Business Integrity establish
procedures to ensure accurate coding for the 11 third-tier specialties
implementing RVU-based productivity standards.
Target date for completion: October 2015.
Incorporate specialty practice management tools (Quadrant
Report) and Specialty Physician Workforce Reports into specialty
physician staffing assessments for the 11 third-tier specialties.
Target date for completion: October 2015.
Table 1.
----------------------------------------------------------------------------------------------------------------
Total Worked MD Worked FTE Imputed Fee &
Aggregate Specialty FTE (Clinical) Contract MDFTE % Total FTE Status:
----------------------------------------------------------------------------------------------------------------
Internal Medicine 5043.48 4436.93 542.71 33.77% Complete
Psychiatry 2147.69 1810.94 96.49 14.38% Complete
Radiology 829.96 711.16 282.07 5.56% Complete
Anesthesiology 553.89 491.62 3.71%
Cardiology 505.12 419.39 40.51 3.38%
Surgery 462.48 375.10 76.12 3.10%
Physical Medicine & 432.53 354.66 19.01 2.90%
Rehabilitation
Geriatric Medicine 413.61 296.51 13.19 2.77%
Neurology 412.57 302.05 31.17 2.76%
Critical Care / Pulmonary 410.33 300.24 13.86 2.75%
Disease
Emergency Medicine 398.12 366.63 153.27 2.67%
Pathology 353.68 276.39 41.14 2.37%
Gastroenterology 347.11 278.37 41.01 2.32%
Ophthalmology 293.62 266.39 75.68 1.97%
Hematology-Oncology 281.29 220.70 12.12 1.88%
Orthopedic Surgery 257.30 234.36 64.79 1.72%
Nephrology 245.54 166.75 21.35 1.64%
Urology 222.37 198.61 52.89 1.49%
Infectious Disease 212.32 126.40 9.10 1.42%
Endocrinology 185.66 124.61 8.05 1.24%
Dermatology 141.21 116.65 35.77 0.95%
Rheumatology 133.95 93.88 8.92 0.90%
Otolaryngology 133.72 117.26 29.18 0.90%
Vascular Surgery 114.82 91.39 18.35 0.77%
Thoracic Surgery 95.09 76.32 30.04 0.64%
Plastic Surgery 64.62 58.30 12.12 0.43%
Neurological Surgery 62.92 50.28 23.47 0.42%
Obstetrics & Gynecology 57.83 53.63 9.12 0.39%
Pain Medicine 48.19 40.82 1.90 0.32%
Preventive Medicine 40.67 32.50 6.55 0.27%
Allergy and Immunology 31.10 23.50 7.79 0.21%
Clinical Pharmacology 1.84 1.84 0.07 0.01%
Medical Genetics 1.10 0.33 0.01 0.01%
Grand Total 14,935.71 12,514.51 1,777.80 100%
----------------------------------------------------------------------------------------------------------------
Appendix A.
Specialty Practice Review Sheet
Step 1: Open the Proclarity Briefing Book to get Provider-specific
Productivity data for each specialty.
Step 2: Check Person Class Status for your Providers:
Ensure all contributing Providers are included.
Ensure no contributing Providers are excluded.
For any inclusions or exclusions, check the Provider
Person Class and make corrections via your service ADPAC.
Report any change made.
Step 3: Evaluate workload to ensure that RVUs counts are consistent
with expected results.
Investigate any apparent under or over-counting of
workload.
Evaluate if there are problems with inpatient workload
capture. Would it make a difference in what you do
Evaluate if there are problems with resident workload
capture.
Evaluate if there is a problem with coding of workload.
Report any changes you made.
Step 4: Evaluate the assigned MD FTEE in the Productivity Cube for
each Provider.
Navigate this Excel workbook to the tab for this
Specialty. It includes your current dSs mapping as of PP2.
Compare current mapping to the cube to determine whether
there are obvious discrepancies.
Step 5: For each provider for whom you would map research, admin,
or teaching time, navigate to the Tab in this worksheet with the
business rules for mapping their time. You are only required to re-map
providers who you are assigning protected time for Administration,
Research, or Education. You may copy the Tabs to create separate
mappings for each Provider that you can use for reference. These new
rules were developed as working drafts by assigned SME so that we can
apply consistent and rigid allocations of protected time. Review all
the Providers in this specialty and re-map on the spreadsheet using the
new rules.
If you are going to allocate discretionary time, identify
that time separately in the mapping worksheet. This time will be
considered above ceiling and comments must be included to justify the
mapping.
Evaluate changes in mapping and consider the impact on
productivity.
Identify any concerns you had about the business rules
and how to apply them.
Check the assigned direct patient care time. Ensure that
there are active clinics or inpatient assignments that match the level
of effort assigned.
Report any changes you made.
Step 6: Review whether you have an Access problem using specialty-
specific productivity measures and the preliminary productivity
standards.
Specialties should not have low productivity and access
problems.
Specialties with low productivity and no access problems
should consider rebalancing resources.
Sites should explain variance from the above assumptions.
Step 7: Provide a Summary Review of each specialty.
Assess whether your review resulted in any changes that
would impact the productivity calculation.
Assess any other facility-specific issues that impact
your specialty that should be considered in the productivity
calculation.
Include other comments for consideration to include any
ideas you have for improving our process for evaluating productivity.
Provide an action plan that would implement any positive
steps you would take to improve the productivity of your specialty.
Step 8: Save this worksheet and upload it, along with all of your
other Specialty areas selected for review, to the SharePoint site XXXX
and send an email confirming that the upload was completed to the VISN
office with a copy to XXX by COB XXX. If you have any questions, please
contact XXX.
Questions For The Record
Letter From: Hon. Dan Benishek, Chairman, Subcommittee on Health,
To: Veterans Health Administration
March 25, 2013
Madhulika Agarwal M.D., M.P.H.
Deputy Under Secretary for Health for Policy and Services
Veterans Health Administration
U.S. Department of Veterans Affairs
810 Vermont Avenue, NW
Washington, DC 20420
Dear Dr. Agarwal:
On Wednesday, March 13, 2013, you testified before the Subcommittee
on Health during an oversight hearing entitled, ``Meeting Patient Care
Needs: Measuring the Value of VA Physician Staffing Standards.'' As a
follow-up to that hearing, I request that you respond to the attached
questions and provide the requested materials in-full by no later than
close of business on Friday, April 26, 2013.
If you have any questions, please contact Dolores Dunn, Staff
Director for the Subcommittee on Health, at [email protected]
or by calling (202) 225-9154.
Your timely response to this matter is very much appreciated.
Sincerely,
DAN BENISHEK M.D.
Chairman
Subcommittee on Health
Questions From: Hon. Dan Benishek, Chairman, Subcommittee on
Health, Hon. Tim Huelskamp, and Hon. Jackie Walorski, To: Veterans
Health Administration
Questions from Hon. Dan Benishek, Chairman
1. In response to a question from Ranking Member Brownley regarding
how VA productivity standards compare to private sector productivity
standards, you stated that, `` . . . our productivity levels are best
measured by like specialties and like facilities . . . '' However, the
December 2012 Department of Veterans Affairs (VA) Inspector General
(IG) Audit of Physician Staffing Levels for Specialty Care Services
describes a situation where a facility classified as ``1a'' had .8
Full-Time Equivalent (FTE) providing endocrinology care to 1,053 unique
patients for a total of 1,627. Meanwhile, a facility also classified as
``1a'' had .4 FTE that provided endocrinology care to 1,347 unique
patients for a total of 2,286 encounters. How do you account for such
widespread disparities in efficiency among VA medical facilities of a
similar size, complexity level, and patient population and what steps
are you taking to address such inefficiencies? Please be specific.
2. Please provide the current physician-to-support-staff ratio at
each VA medical center.
3. Regarding the pilot programs that have been initiated in
Veterans Integrated Service Networks (VISNs) 7, 12, 19, and 22, please
provide the following: (1) starting and ending dates for the pilot
programs: (2) the criteria used to choose the four selected VISNs for
the pilot programs; (3) the criteria and/or any other standards used to
measures the pilot program's performance; (4) any and all guidance sent
to the field regarding the pilot programs; and, (5) information
regarding the pilot program's implementation and status to-date.
4. According to the IG, none of the five VA medical facilities
visited during the December 2012 audit used the Physician Productivity
Cube. What actions have been taken to-date and/or what actions are
planned for the future to inform and educate VA medical facility
leaders about the Cube's existence and intended use?
5. What actions has VA taken and/or is VA planning to take to
provide medical facilities with more specific guidance on how to
develop appropriate staffing plans? Please provide a copy of any and
all such guidance that has been issued to the field to-date.
6. What justification is required when a VA medical facility
requests additional staff and what oversight is conducted at the
facility, VISN, and VA Central Office levels when staffing decisions
are being made? Please be specific.
7. What are the five additional specialties that VA will establish
productivity models for in coming year?
8. Under the Primary Care Panel Size Staffing Model, how many
active patients may be assigned to each primary care provider and why?
Please be specific.
9. When will VA distribute the, ``Productivity Guidance for Mental
Health Providers?'' Will you provide the Subcommittee with a copy of
that directive when it is complete?
10. The IG suggested developing a staffing model based on best
practices. Currently, does VA have the capability to capture and track
the necessary information to develop such a staffing model? If so,
explain in detail what systems are in place and how VA captures,
tracks, and uses such information now.
11. How does the VA define an ``encounter?''
Question from Congressman Tim Huelskamp
1. Please provide an update regarding the Liberal, Kansas
Community-based Outpatient Clinic, which is currently operating without
either a doctor or a nurse practitioner. The facility has not had a
nurse practitioner for over two years and has been without a doctor
since December 2011 - almost fifteen months. Please provide an
explanation for these vacancies and list any and all actions taken to-
date to fill them in order to provide care for veterans in Liberal and
the greater Western Kansas community.
Questions from Congresswoman Jackie Walorski
1. In your testimony, you acknowledge that VA is primarily
concerned with improving the health of veterans and in reorienting the
system towards delivering more ``proactive, personalized and patient-
driven care.'' Can you explain how we are to believe this when the VA
has failed to make simple changes based upon recommendations going back
as far as 1981?
2. Why has the VA failed to implement physician staffing standards
knowing how detrimental this is to providing quality care to our
veterans?
3. When reading the December 27, 2012, IG audit, did you find it
alarming that certain specialties were understaffed, therefore,
significantly increasing patient risk? Why or why not?
4. Without appropriate staffing standards and procedures in place,
how does VA evaluate physician productivity? Do you agree that such
evaluations are necessary for ensuring proper patient care as well as
making sure VA dollars are spent appropriately? Why or why not?
Questions and Responses From: Veterans Health Administration, To:
Hon. Dan Benishek, Chairman, Subcommittee on Health, Hon. Tim Huelskamp
and Hon. Jackie Walorski
1. In response to a question from Ranking Member Brownley regarding
how VA productivity standards compare to private sector productivity
standards, you stated that, ``...our productivity levels are best
measured by like specialties and like facilities...'' However, the
December 2012 Department of Veterans Affairs (VA) Inspector General
(IG) Audit of Physician Staffing Levels for Specialty Care Services
describes a situation where a facility classified as ``1a'' had .8
Full-Time Equivalent (FTE) providing endocrinology care to 1,053 unique
patients for a total of 1,627. Meanwhile, a facility also classified as
``1a'' had .4 FTE that provided endocrinology care to 1,347 unique
patients for a total of 2,286 encounters. How do you account for such
widespread disparities in efficiency among VA medical facilities of a
similar size, complexity level, and patient population and what steps
are you taking to address such inefficiencies? Please be specific.
Response: A comparison of productivity or efficiency based solely
upon the number of unique patients treated and the number of patient
encounters is problematic. To accurately compare productivity and
efficiency requires a measure that accounts for the complexity and
intensity of services provided during those encounters, as well as
consideration of factors such as support staff levels. Accordingly, the
Veterans Health Administration (VHA) is utilizing Relative Value Units
(RVU) to more accurately compare the productivity and efficiency of
specialty physician services. Because each encounter generates a
specific Current Procedural Terminology code that can be associated
with a RVU, it is possible to ensure that comparisons of productivity
and efficiency can be made.
We, too, have concerns about the variations depicted in the
Inspector General's (IG) report. To that end, we designed a Veterans
Integrated Service Network (VISN) Pilot to help us understand and
remediate inefficiencies. The effort is focused on: (1) addressing the
issues of accurate coding and workload capture; (2) consistent
application of business rules to account for physician time of effort
associated with direct patient care, research, medical education, and
administrative responsibilities; and (3) capture of resident workload
and association of that workload to supervising Department of Veterans
Affairs (VA) staff physicians across seven specialties.
2. Please provide the current physician-to-support-staff ratio at
each VA medical center.
Response: Within VHA there are over three dozen physician
specialties practicing in a variety of settings (Medical Center
Complexity Levels, Community-Based Outreach Clinics (CBOC), etc.).
There is no one support staff ratio that will fit every practice.
However, benchmarks can assist local managers in developing adequate
support staff levels. VHA maintains such benchmarking tools by
specialty and complexity level in the Specialty Physician Workforce
Reports. The Specialty Physician Workforce Reports provide a benchmark
for a clinic or `office-based' practice. For example, in fiscal year
(FY) 2012, an Orthopedic Surgery clinic in VHA had a support staff
ratio of 1.42 per 1.0 Orthopedic Surgeon; whereas an Ophthalmology
Clinic had a support staff ratio of 2.59 per 1.0 Ophthalmologist. VISN
pilots are currently evaluating support staff ratios as part of the
work underway in establishing FY 2013 specialty productivity standards.
It should be noted that because most outpatient specialty practices
share support resources as their duties include both outpatient clinics
and inpatient services and procedures, variation exists within the
labor mapping assignments of these support staff among the different
specialty practices they support. This creates variation between
practices, when compared at the national level that results from the
labor mapping within the VHA Decision Support System. VISN pilots will
seek to understand and manage this variation.
3. Regarding the pilot programs that have been initiated in
Veterans Integrated Service Networks (VISN) 7, 12, 19, and 22, please
provide the following: (1) starting and ending dates for the pilot
programs; (2) the criteria used to choose the four selected VISNs for
the pilot programs; (3) the criteria and/or any other standards used to
measures the pilot program's performance; (4) any and all guidance sent
to the field regarding the pilot programs; and, (5) information
regarding the pilot program's implementation and status to date.
Response: The four VISN Pilots (VISN 7, 12, 19, and 22) were
selected to ensure an appropriate spectrum of U.S. regions (South,
East, Midwest, and West, as well as a mix of rural and urban) and
practice settings (Medical Center Complexity Group (MCG) Levels) are
included, as well as to ensure a core group of VISNs can assist in the
diffusion of core competencies in specialty practice management
knowledge.
The four VISN Pilots began focusing on seven specialties in January
2013 with a target date for completion by October 2013. They were
tasked with simulating productivity standards implementation and
reviewing factors associated with productivity outliers such as
inconsistent application of foundational business rules (person class
designation, labor deployment, and professional workload capture) and
modifying business rules accordingly.
VISN Pilots were also tasked with: (1) reviewing the Office of
Productivity, Efficiency, and Staffing (OPES) methodology for capturing
professional services associated with inpatient care for accuracy and
inclusion in productivity assessment; (2) reviewing other factors
contributing to productivity including practice setting, support staff,
specialty demand, contract and Fee Basis Care, and coding accuracy; (3)
reviewing and refining specialty management tools (Quadrant Report) and
algorithms for assessing specialty physician staffing; and (4)
communicating and establishing core competencies within medical centers
on effective specialty practice management inclusive of use of tools
(Physician Productivity Cube (PPC), VHA Specialty Physician
Benchmarking Report, and Specialty Physician Workforce Reports).
To assist the VISN Pilots, OPES: (1) established preliminary
productivity standards (25th percentile and mean values for MCG Level)
for the Specialties of: Cardiology, Gastroenterology, Neurology,
Dermatology, Ophthalmology, Urology, and Orthopedics in VISN Pilots;
(2) developed and refined specialty practice management tools (Quadrant
Report) and Specialty Physician Workforce Reports that integrate
productivity and access measures for medical center leadership to
critically assess specialty physician staffing and make informed
decisions on the appropriate numbers of specialty physicians to meet
patient care needs; (3) developed a methodology for capturing
professional services associated with inpatient care for medical
specialties; and, (4) provided preliminary productivity standards for
the seven specialties for all VISN Pilot sites and identified outliers
falling below 25th percentile and mean values.
The attached operational plan details specific actions already
completed and guidance for VISN Pilots to review productivity data, as
well as goals and target dates for completion.
4. According to the IG, none of the five VA medical facilities
visited during the December 2012 audit used the Physician Productivity
Cube. What actions have been taken to-date and/or what actions are
planned for the future to inform and educate VA medical facility
leaders about the Cube's existence and intended use?
Response: All sites have access to PPC and with each quarterly
update an e-mail distribution to all users inclusive of Chiefs of Staff
and Chief Medical Officers are notified of the cube update. More
recently, medical center directors have been added to this e-mail
distribution.
The attached operational plan details specific actions related to
informing and educating VA medical facility leaders about the PPC and
its intended use. Specifically, VISN Pilots will communicate and help
to establish core competencies across all VISNs on effective specialty
practice management tools (and reports including PPC, VHA Specialty
Physician Benchmarking Report, and Specialty Physician Workforce
Reports).
In addition, attached are Web-hit reports for PPC as well as the
briefing books.
5. What actions has VA taken and/or is VA planning to take to
provide medical facilities with more specific guidance on how to
develop appropriate staffing plans? Please provide a copy of any and
all such guidance that has been issued to the field to-date.
Response: To link productivity measurement to staffing standards,
VA developed a Web-based tool that integrates specialty physician
productivity data and measures of access to specialty care into an
algorithm to guide staffing decisions of specialty care physicians.
This integrated approach, coupled with measures of quality and the
amount of specialty non-VA community care (Fee-Basis care), was
proposed to help VA medical center leaders make informed decisions on
the appropriate numbers of specialty physicians to meet patient care
needs. Productivity data coupled with access measures provides a
framework for determining specialty physician staffing. This model was
prototyped for the seven specialties of Cardiology, Gastroenterology,
Dermatology, Neurology, Orthopedics, Urology, and Ophthalmology.
The idealized staffing model considers:
The productivity of the specialty practice or service;
and
The performance (access and quality) standards.
Specialty physician staffing could be defined as adequate when
both:
The specialty practice's productivity falls within an
acceptable productivity range; and,
Access to the specialty service by Veterans meets VA
waiting time performance standards.
When access performance standards (waiting times and waiting lists)
and Quality standards are not being met at a particular site,
facilities should determine whether access imbalance is related to:
Inadequate individual provider productivity;
Inadequate systems to support high productivity, such as
support staff, infrastructure; or
Inadequate specialty physician supply.
The attached operational plan details efforts VA has completed
including the development of a Quadrant tool, algorithms, and practice
reports that VISN Pilots will test and refine for the seven
specialties.
6. What justification is required when a VA medical facility
requests additional staff and what oversight is conducted at the
facility, VISN, and VA Central Office levels when staffing decisions
are being made? Please be specific.
Response: There are three distinct processes, based on the grade
level, which guide the approval of new positions. The separate
processes are for:
Grades GS-14 or lower, with the exception of GS-14
Associate/Assistant Directors;
GS-15 and GS-14 Assistant/Associate Directors; and
Senior Executive Service (SES) positions.
VA medical center (VAMC) leadership approves positions at the GS-14
level and below, with the exception of GS-15 and GS-14 Assistant and
Associate Director positions. The VAMC Resources Management Committee
(RMC) reviews requests for additional staffing allocations. These
requests must include detailed justifications submitted by the
initiating organization. Some examples of this information include
supporting clinical and administrative workload, the impact the
additional staffing request to alleviate workload issues, and cost and
any additional data needed for RMC deliberation. If the RMC endorses
the request, it is then forwarded to the medical center director for
final approval. Oversight at the VISN and VA Central Office levels is
primarily focused on the cumulative budget expenditures for overall
salaries.
GS-15 and GS-14 Assistant and Associate Medical Center Director
positions are reviewed by the Leadership Management and Succession
Subcommittee (LMSS). LMSS is a subcommittee of the VHA National
Leadership Council's Workforce Committee, responsible for reviewing and
submitting the nomination packages for the Under Secretary for Health
(USH) approval.
The USH has indicated that senior executive positions are one of
the most significant resource issues VHA faces. The USH uses both SES
and Title 38 SES equivalent executive positions to assist in carrying
out VHA's mission to honor America's Veterans by providing exceptional
health care that improves their health and well-being. The USH approves
all VHA selections that are forwarded to the Secretary of VA, who
maintains centralized final approval authority for all executive
appointments.
VHA has established a comprehensive executive recruitment process
through the partnership between VA Corporate Senior Executive
Management Office (CSEMO) and VHA's Executive Recruitment Office. This
collaboration utilizes the direct involvement of both VA and VHA senior
leadership. The VA Chief of Staff meets weekly with VHA leaders to
review the status of each senior executive vacancy. These meetings
expedite the hiring process and ensure that VHA is recruiting the best
qualified candidates for leadership positions. Additionally, VHA
leadership meets weekly with CSEMO to develop strategies and action
plans that improve the executive hiring process.
7. What are the five additional specialties that VA will establish
productivity models for incoming year?
Response: In FY 2013, productivity standards are being established
for the specialties of Gastroenterology, Dermatology, Neurology,
Orthopedics, and Urology.
8. Under the Primary Care Panel Size Staffing Model, how many
active patients may be assigned to each primary care provider and why?
Please be specific.
Response: VHA policy detailing expected panel sizes for primary
care clinics is documented in VHA Handbook 1101.02 Primary Care
Management Module. Panel size determination is calculated based on
patient characteristics of the Veteran population, reliance on VHA,
staff, space and local determination. Expected panels for VHA primary
care (patient-aligned care teams) physicians largely fall in the range
of 1,000 to 1,400. Veterans from special populations (e.g., women's
health, elderly, end-stage renal disease, Veterans returning from
combat) may require additional time and resource-intensive care
management and care coordination to provide high quality care. Nurse
practitioners and physician assistants are expected to have a panel
size of 75 percent of a physician's panel.
9. When will VA distribute the ``Productivity Guidance for Mental
Health Providers?'' Will you provide the Subcommittee with a copy of
that directive when it is complete?
Response: The directive entitled ``Productivity Guidance for Mental
Health'' is in the final stages of VHA's approval process, and we
anticipate that it will be published in July 2013. A copy of the
directive will be provided to the Subcommittee upon publication.
10. The IG suggested developing a staffing model based on best
practices. Currently, does VA have the capability to capture and track
the necessary information to develop such a staffing model? If so,
explain in detail what systems are in place and how VA captures,
tracks, and uses such information now.
Response: Specialty-specific ``best practices'' data are now
available via the PPC for productivity performance; when coupled with
access measures, in the Practice Management Tool, VHA can identify
``optimized specialty practices'' given these two dimensions.
The `penultimate' staffing model includes specialty-specific
patient quality and/or outcomes data. Currently, both within VHA and
externally, data are not mature enough to handle the necessary
specialty physician attribution necessary in such a model. Much work,
again within VHA and externally, is necessary. Currently, the Center
for Medicare and Medicaid Services (CMS), through such systems as the
Patient-Centered Episode System, are working to consider episodes as
they occur and interact at the patient level. Allocating services when
there are concurrent episodes that overlap and require multiple
specialist physicians to treat a single patient is very complex, but
this allocation is necessary to ultimately understand the value of our
specialist workforce.
11. How does the VA define an ``encounter?''
Response: An encounter is a professional contact between a patient
and a practitioner vested with primary responsibility for diagnosing,
evaluating, and/or treating the patient's condition. Encounters occur
in both the outpatient and inpatient setting. Contact can include face-
to-face interactions or those accomplished via telemedicine technology.
Source: VHA Directive 2009-002.
Questions from Congressman Tim Huelskamp
1. Please provide an update regarding the Liberal, Kansas
Community-Based Outpatient Clinic, which is currently operating without
either a doctor or a nurse practitioner. The facility has not had a
nurse practitioner for over two years and has been without a doctor
since December 2011 - almost fifteen months. Please provide an
explanation for these vacancies and list any and all actions taken to-
date to fill them in order to provide care for veterans in Liberal and
the greater Western Kansas community.
Response: The Robert J. Dole VAMC identified two critical issues in
provider staffing challenges. These include hiring specialists for the
main campus in Wichita, Kansas, and hiring a provider for the Liberal,
Kansas, CBOC.
The Dole VAMC designed plans to expand specialty capability in
alignment with the VISN 15 Strategic Plan and in concert with the
University of Kansas-Wichita School of Medicine. To date, specific
successes lie in expansion of Orthopedic Surgery, Pain Management, and
initiation of a Spine Service including both operative and non-
operative management. Other established specialties remain stable with
plans for overall growth in the medical center.
The acquisition of physician or mid-level provider coverage at the
Liberal CBOC presented challenges. Since March 2012, the VA Healthcare
Recruitment Consultant in Leavenworth, Kansas, has sent 20 broadcast e-
mails to focused physician groups to solicit interest in the Liberal
CBOC. Five physicians responded to the marketing efforts. Two accepted
offers with one of the two later declining. The second candidate is
currently in the hiring process, with an anticipated start date of
summer 2013.
To provide services for the 175 Veterans enrolled in the Liberal
CBOC, the medical center plans include:
Wichita campus Advanced Practice Registered Nurse
provides telemedicine coverage every Wednesday;
Parsons CBOC Advanced Practice Registered Nurse provides
telemedicine coverage every Thursday and two Fridays monthly;
Continue current staff at the Liberal CBOC (one
Registered Nurse, one Licensed Practical Nurse, and one receptionist)
daily for triage and patient assistance. For the days without scheduled
telemedicine coverage, a designated provider at the Wichita main campus
supports the Liberal staff. Regular physician on-site coverage is
anticipated in the summer of 2013. With this hire, the physician will
be stationed part-time at Liberal but available by telemedicine when
off-site at the Hutchison CBOC.
A decision to hire a J-1 physician was made as all attempts to hire
a United States citizen and permanent candidates for Liberal over the
last couple of years have been exhausted. The candidate was selected
February 2013 and accepted the position; the provider will work part-
time in Liberal and part time in the Hutchinson clinic. The physician
is expected to start at the clinic in a few months, depending on the
amount of time the administrative process will take. In the meantime,
coverage has been via telemedicine services from other Primary Care
clinics to meet the patient care needs at the Liberal CBOC.
Human Resource staff continues to work with the National
VHA Recruitment consultant, Mr. James Marfield, to hire a full-time
provider for the Liberal clinic.
Questions from Congresswoman Jackie Walorski
1. In your testimony, you acknowledge that VA is primarily
concerned with improving the health of veterans and in reorienting the
system towards delivering more ``proactive, personalized and patient-
driven care.'' Can you explain how we are to believe this when the VA
has failed to make simple changes based upon recommendations going back
as far as 1981?
Response: VA has already established productivity standards for
more than half (54 percent) its physicians; has been analyzing and
reporting RVU productivity data for all specialists since 2008; and has
committed to establishing productivity standards for five specialties
by the end of this year. The Specialty Physician Productivity and
Staffing Task Force (Task Force) has concentrated on establishing RVU-
based productivity standards for seven additional specialties
representing an additional 15 percent of VHA's physician workforce, so
that by the end of FY 2013, more than two-thirds of physicians in VA
will have productivity standards.
Primary Care, the largest component of our physician workforce (34
percent), has been employing a panel model for standardizing
productivity and staffing in primary care since 2004. Mental Health,
the second largest component of our physician workforce (14 percent),
has developed a productivity model that will be implemented this year.
Radiology, the third largest component of our physician workforce (6
percent), has employed an RVU-based productivity model that has set a
productivity standard of 5,000 RVUs/Full-Time Equivalent (FTE) since
2008 directive.
VA has already established a system for collecting, analyzing, and
reporting RVU productivity data for all medical specialties. In 2007,
VA established OPES and in 2008 began reporting physician productivity
using RVUs. VA has provided specialty physician productivity data
utilizing RVUs on the VA Intranet PPC to VA managers since 2008. The
productivity data utilized by the IG was derived from this VA physician
productivity report.
In developing the primary care staffing model that was implemented
in 2004, our goal was to establish a primary care system that balances
productivity with quality, access, and patient service. In addition,
the staffing model permits VHA to measure the overall productivity of
primary care providers and the capacity of our system, in order to
understand and inform our primary care staffing needs. Currently, we
are completing the process of updating that model to reflect changes
associated with VHA's deployment of patient-aligned care teams at all
our sites of care.
The second largest component of our physician workforce is our
mental health providers. Psychiatrists now account for 14 percent of
VA's physician workforce. Mental Health has experienced unprecedented
growth in the past 2 years--driven by sharply increasing demand for
mental health services. VHA has comprehensively studied our mental
health provider resources to ensure that they are optimally deployed
and used. We will be distributing a directive providing guidance for
facilities to support this objective titled, ``Productivity Guidance
for Mental Health Providers,'' by July 2013.
While many private sector health care organizations use the
industry-accepted metric of work RVUs (wRVUs) to determine
productivity, wRVUs also are used in academic and private practices to
determine physician compensation. VHA intends to expand the use of
wRVUs as only one of several measures to assess the productivity and
efficiency of each specialty practice area throughout the organization.
Radiology, the third largest component of our physician workforce
(nearly 6 percent of the total workforce), offers a good example of how
wRVUs can be used to set productivity levels. A comprehensive study of
the productivity of VA radiologists was performed in FY 2005 and
radiology productivity standards were implemented in 2008.
In June 2012, VA established a task force to recommend and
establish productivity standards in five specialties by the end of FY
2013, and to develop a plan to ensure that all specialties have
productivity standards by the end of FY 2015. To link productivity
measurement to staffing standards, the Task Force developed a Web-based
tool that integrates specialty physician productivity data and measures
of access to specialty care into an algorithm to guide staffing
decisions of specialty care physicians. This integrated approach,
coupled with measures of quality and the amount of specialty non-VA
community care (Fee-Basis Care), was proposed to help VAMC leaders make
informed decisions on the appropriate numbers of specialty physicians
to meet patient care needs. Productivity data coupled with access
measures provides a framework for determining specialty physician
staffing. This model was prototyped for the seven specialties of
Cardiology, Gastroenterology, Dermatology, Neurology, Orthopedics,
Urology, and Ophthalmology.
2. Why has the VA failed to implement physician staffing standards
knowing how detrimental this is to providing quality care to our
veterans?
Response: Productivity standards are not the same as physician
staffing standards. Although wRVUs are increasingly being employed in
the private sector to measure physician productivity, physician
staffing standards only exist for just a few of the more than 36
physician specialties. Staffing standards typically are only applied to
hospital-based 24/7 services such as Emergency Medicine and
Hospitalists. These specialties represent a very small fraction of
VHA's physicians. For hospital care, the most critical staffing
requirements for ensuring quality care to Veterans are nursing staffing
standards since nurses are at the very front line of health care
delivery and provide 24/7 care to inpatients. VA has well-established
nursing staffing standards that are specific for the location of care
(psychiatry, medicine, surgery, intensive care, etc.) in place for all
VAMCs.
Specialty physician productivity standards and physician staffing
are complex issues. Multiple variables influence both. Productivity is
an essential component to evaluate staffing but managers need to
incorporate other contributing factors such as access, clinical setting
and support staff, and patient needs to assess specialty physician
staffing levels. VA has created a framework that integrates specialty
productivity data and access measures to guide staffing decisions. This
approach coupled with measures of quality and non-VA community care
will help VAMC leaders make informed decisions on the appropriate
number of specialty physicians to meet our Veteran's needs and provide
quality care.
3. When reading the December 27, 2012, IG audit, did you find it
alarming those certain specialties were understaffed, therefore,
significantly increasing patient risk? Why or why not?
Response: The IG audit examined productivity based upon wRVUs. As
part of the audit, the IG noted variation in productivity--identifying
both low and high outliers in terms of productivity or RVU generation
per clinical FTE for various specialties. The IG did not equate either
decreased productivity or increased productivity to either
understaffing or overstaffing. Determining appropriate levels of
specialty physician staffing from productivity is much more complex.
For example, high productivity might mean that specialty physician
staffing is appropriate and physicians are working hard and being
clinically productive. High productivity could also mean that specialty
physician staffing is inadequate and physicians are working hard to
compensate for being short-staffed. Moreover, high productivity could
potentially mean that specialty physician staffing is adequate and
physicians are working hard but other factors are contributing to
physicians feeling harried (inadequate support staff, clinic
inefficiency, and excessive clinical demand due to inappropriate
specialty referrals). A simple measure of productivity alone (RVUs/FTE)
cannot discriminate between these different scenarios.
Conversely, low productivity could mean that specialty physician
staffing is excessive or it could mean that physician staffing is
appropriate but productivity is being limited due to inadequate support
staff or clinic inefficiency. Our understanding is that the IG did not
examine these other contributing factors and did not equate high or low
productivity to understaffing.
Adequate staffing results when supply of clinical services is
adequate to meet demand. However, demand for clinical care is also
complex. The demand for clinical services varies across the United
States and this variation in care is not limited to VA. In some parts
of the country, there is sufficient care, while in other areas care is
limited. In some cases, the amount of care provided in the United
States is driven not by need, but by local availability and local
practices. More care does not necessarily equal higher quality and
improved outcomes. In fact, former CMS administrator Donald Berwick
M.D., estimated that 20-30 percent of all health spending was of no
benefit to patients, and a coalition of 25 medical specialty societies
and 15 consumer organizations have recently launched a national
campaign to reduce use of more than 100 overused tests and treatments.
Ironically, ``doing less'' takes more time than ``doing more'' (e.g.,
explaining to a patient why antibiotics are unnecessary and might be
harmful rather than simply writing a prescription).
Measures of access (waiting times) represent the balance of the
demand for care and the availability of care. Within VA, there was no
correlation between productivity and access--specialties with long
waiting times were as likely to have average productivity levels as
they were to have below average productivity levels.
4. Without appropriate staffing standards and procedures in place,
how does VA evaluate physician productivity? Do you agree that such
evaluations are necessary for ensuring proper patient care as well as
making sure VA dollars are spent appropriately? Why or why not?
Response: VHA believes it is essential to ensure that all employees
within our Administration, including our physicians, are able to work
as effectively as possible to provide appropriate, high-quality care
and services and meet the needs of Veterans. VHA currently uses both
population-based (primary care physicians) and work value-based
(specialist physicians) models to assess physician productivity. VHA is
committed to establishing appropriate productivity models for five
additional specialties by the close of this FY. Over the next 3 years,
we will refine and develop additional models that are individualized
for specialty care.